Vaccine Consent Form
Super Health Pharmacy Linden, NJ | Phone: (908) 718-5459
Are you or the patient who is receiving the vaccine of 3 years of age and older? (If less than 18 years of age, parent/guardian must be present)
Yes
No
Select an appointment time for the vaccine for the COVID-19 Vaccine
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Vaccine Recipient Phone Number
*
Format: (000) 000-0000.
Primary Care Provider Name
Please provide if you want us to fax proof of vaccine to your doctor
Emergency Contact Name
Phone Number of Emergency Contact
Format: (000) 000-0000.
Email
*
example@example.com
Vaccine Screen Questions
*
Rows
Yes
No
1. Are you sick today?
2. Do you have allergies to food, medications, or any vaccine?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have seizures or a brain condition?
5. Have you received any vaccine in the last 14 days?
6. For women: are you pregnant or is there a chance you could become pregnant during the next 3 months?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer, or do you take immunosuppressive drugs or therapies?
8. Do you take any medications that affect your immune system, such as cortisone, prednisone, or other steroids, anticancer drugs, or have you had any radiation treatments?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. I request that the pharmacist SENDS a copy of my vaccine document to my primary care provider.
Vaccine (select all vaccines you would like to receive)
Flu Vaccine
Moderna Spikevax COVID Vaccine 2025-2026
Pfizer Comirnaty COVID Vaccine 2025-2026
Shingles Vaccine (For ages 50 and up)
Pneumonia Vaccine/Prevnar 20 (For ages 65 and up)
RSV Vaccine (For ages 60 and up)
Tdap Vaccine
Which arm would you like to get the injection on?
*
Left Arm
Right Arm
*
Rows
Check each box
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
Please Upload Insurance Card. The vaccines are usually FREE with insurance, please upload a picture of your insurance card. If you don't have insurance, please inquire with our staff about our discount vaccine prices
Browse Files
Drag and drop files here
Choose a file
Cancel
of
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
*
Date Signed
*
/
Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Pharmacy Name
Submit
Pharmacy NPI
*
Should be Empty: