General Vaccine Consent Form

General Vaccine Form

500 4th Ave, Brooklyn, NY 11215
Park Chemists Location*
Park Chemists Street*
Park Chemists Zip Code*
Park Chemists Phone*
Online Scheduling*
Vaccine Options

Select up to 2 vaccines you want to receive
Vaccine Choice 1*
Vaccine Choice 1 - Name*
Vaccine Choice 1 - Manufacturer *
Vaccine Choice 1 - VIS DATE*
YesNo
Vaccine Choice 2
Vaccine Choice 2 - Name
Vaccine Choice 2 - Manufacturer
Vaccine Choice 2 - VIS DATE
One of the vaccine options you have selected have been marked as out-of-stock. Due to this, you will not be able to submit this form unless you change your vaccine option(s).
YesNo
YesNo
- Prevnar 20 Eligibility
- To determine a patient's eligibility for the Prevnar 20 vaccine, please review the risk conditions for Pneumococcal disease listed below.
  
  Pneumococcal Risk Conditions for Age 18 years
  - Cerebrospinal fluid leak
  - Chronic heart disease, particularly cyanotic congenital heart disease and cardiac failure
  - Chronic kidney disease (excluding maintenance dialysis or nephrotic syndrome)
  - Chronic liver disease
  - Chronic lung disease, including moderate persistent or severe persistent asthma
  - Cochlear implant
  - Diabetes mellitus
  Pneumococcal Risk Conditions for Ages 19-49 years
  - Alcoholism
  - Cigarette smoking
  - Cerebrospinal fluid leak
  - Chronic heart disease, including congestive heart failure and cardiomyopathies (excluding hypertension)
  - Chronic liver disease
  - Chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma
  - Cochlear implant
  - Diabetes mellitus
- The patient is older than 49 years old.The patient is 19-49 years old with risk factorsThe patient is 18 year old with risk factors.None of the above apply to the patient.
- Patient is not eligible for the Prevnar 20 vaccine. Due to this, you will not be able to submit this form unless you change your previous option(s).
- Shingrix Eligibility
- The Shingrex is recommended for the prevention of shingles (herpes zoster). Eligibility is based on a patient's age and immune status. Please review the following information to determine which conditions apply.
  
  Shingrex Eligibility Conditions
  - For Immunocompetent Adults:
    
    Age 50 years and older.
  - For Immunocompromised Adults:
    
    Age 19 years and older who are, or will be, immunodeficient or immunosuppressed due to disease or therapy.
    
    This includes individuals with conditions such as:
    
    Hematopoietic stem cell transplant
    
    Solid organ transplant
    
    Cancer
    
    HIV infection
    
    Autoimmune and inflammatory conditions
    
    Individuals on immunosuppressive medication or therapy
- The patient is 50 years or older.The patient is 19-49 years old and is immunocompromised due to a disease or therapy listed above.None of the above apply to the patient.
- YesNo
- Patient is not eligible for the Shingrix vaccine. Due to this, you will not be able to submit this form unless you change your previous option(s).
- 1st Dose2nd Dose
- RSV Eligibility
- The Centers for Disease Control and Prevention (CDC) recommends the RSV vaccine for adults in this age range who have:
  - Chronic heart disease: (e.g., heart failure, coronary artery disease).
  - Chronic lung or respiratory disease: (e.g., asthma, COPD, cystic fibrosis).
  - A weakened immune system.
  - Certain other underlying medical conditions, such as:
    
    Diabetes (with complications like chronic kidney disease).
    
    Chronic liver disease (e.g., cirrhosis).
    
    Chronic hematologic disorders (e.g., sickle cell disease).
    
    Neurologic or neuromuscular conditions that affect airway clearance or respiratory muscles.
  - Severe obesity: (body mass index ≥40 kg/m²).
- YesNo
- The patient is older than 74 years old.The patient is 50-74 years old with a chronic condition.The patient is within 32-36 gestation of pregnancy.None of the above apply to the patient.
- Patient is not eligible for the RSV vaccine. Due to this, you will not be able to submit this form unless you change your previous option(s).
- The patient has never received a Tdap vaccine before.The patient is due for their 10-year Tdap booster shot.The patient is pregnant (one dose needed during each pregnancy, ideally early third trimester).The patient is a healthcare worker who has contact with infants or young children.The patient has a chronic condition (e.g., heart/lung disease) increasing their pertussis risk.The patient is a grandparent or will be around a newborn/infant.The patient has recently been exposed to pertussis (whooping cough).None of the above apply to the patient.
- Patient is not eligible for the Tdap vaccine. Due to this, you will not be able to submit this form unless you change your previous option(s).
- You have selected the MMR vaccine. Please note the following important scheduling requirements:
  - Other Vaccines at This Appointment: Due to specific guidelines for the MMR vaccine, the option to book an additional vaccine during this same appointment has been automatically disabled.
  - Timing with Previous Vaccines: The MMR vaccine must be administered at least 4 weeks after any other vaccine you (or the person you are booking for) have previously received.
  To proceed to select an appointment date and submit your information, you must acknowledge that you understand this 4-week waiting period.
- I understand
- 3rd Dose4th Dose5th Dose6th Dose
- Your vaccine choices are incompatible with each other. Please change your vaccine choices to be different from each other. You cannot pair two different flu shots, two different COVID-19 vaccines, or other choices intended to protect against the same virus.
- Yes, I meet at least one of the above Moderately or Severely Immunocompromised Criteria.
- YesNo
- Last-dose Date*
  
  MonthDayYear
- Required Last-dose Date Limit*
  
  MonthDayYear
  Date
- Patient Information
- Date of Birth*
  
  MonthDayYear
- Date of Birth Formatted*
  
  MonthDayYear
  Date
- Age
- You do not meet the age requirement for one or more of your vaccine choices. Due to this, you will not be able to submit this form unless you change your vaccine choice(s).
  - Flu Shot (age 12+ yr)
  - Flu Shot for Seniors (age 65+ yr)
  - Prevnar 20 (age 18+ yr)
  - Shingrix (age 19+ yr)
  - Tdap (age 18+ yr)
  - RSV (age 75+, age 50-74 with chronic conditions, or Pregnant)
  - MMR (age 18+ yr)
  - COVID-19 Vaccine Moderna (age 12+ yr)
- Drug Allergies*
- Patient Name*
  
  First NameLast Name
- Parent / Guardian / Surrogate (if applicable)
  
  First NameLast Name
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Phone*
  10-digital phone numberFormat: (000) 000-0000.
- Email*
  example@example.com
- YesNo
- Please note that having insurance will not guarantee coverage. Please call your insurance carrier to confirm prior to your appointment.
- Front of Pharmacy Card*
  
  Cancelof
- Back of Pharmacy Card*
  
  Cancelof
- Patient Questions
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- Which arm would you like the vaccination(s) on?*
- Patient Live Vaccine Questions
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- Patient is not eligible for the MMR vaccine. Due to this, you will not be able to submit this form unless you change your previous option(s).
- YesNo
- Prevaccination Checklist for COVID-19 Vaccines
- What is the FDA’s regulatory framework for COVID-19 vaccination?
  
  On May 20, 2025, the FDA published an updated policy position in the New England Journal of Medicine on an evidence-based approach to COVID-19 vaccination.
  
  The following patient populations are at elevated risk for severe outcomes from COVID-19 infection:
  - Adults aged 65 years or older
  - Individuals ages 6 months or older with one or more underlytingh condfitions that puts theme at high risk for severe COVID-19 outcomes.
  You can see the list of underlying conditions that increase the risk of severe COVID-19 by clicking here.
- The patient is 65+ years old.The patient is between 12-64 years old with one or more underlying conditions (see above link).The patient is under 65 years old and does not have any underlying conditions (see above link).
- YesNoDon't know
- YesNoDon't know
- YesNoDon't know
- PfizerModernaJanssen (Johnson & Johnson)Another Product
- YesNo
- The following questions about allergic reactions would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)
- YesNoDon't know
- YesNoDon't know
- YesNoDon't know
- YesNoDon't know
- Am a female between ages 18 and 49 years oldAm a male between ages 12 and 29 years oldHave a history of myocarditis or pericarditisHad a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergiesHad COVID-19 and was treated with monoclonal antibodies or convalescent serumDiagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infectionHave a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapiesHave a bleeding disorderTake a blood thinnerHave a history of heparin-induced thrombocytopenia (HIT)Am currently pregnant or breastfeedingHave received dermal fillersHistory of Guillain-Barré Syndrome (GBS)
- YesNoDon't know
- YesNoDon't know
- If yes, when did you receive the last dose?*
  
  MonthDayYear
- YesNoDon't know
- YesNoDon't know
- YesNoDon't know
- YesNoDon't know
- YesNoDon't know
- YesNo
- Date of 2nd Pfizer dose?*
  
  MonthDayYear
- YesNo
- Date of 2nd Moderna dose?*
  
  MonthDayYear
- YesNo
- Date of 1st Janssen dose?*
  
  MonthDayYear
- YesNoDon't know
- YesNo
- Date of 3rd Pfizer dose?*
  
  MonthDayYear
- YesNo
- Date of 2nd Janssen dose?*
  
  MonthDayYear
- Consent
- I authorize Park Chemists to report the administration of this immunization to the Citywide Immunization registry (CIR) and my Primary Health Care Provider.
- Patient Signature*
- Submission Date
  
  MonthDayYear
  Date
- Signee Print Name*
- Relationship to Patient, if other than Recipient*
- Please verify that you are human*
- FirstSecond
- Vaccine 2: Which arm would you like the vaccination(s) on?
- Vaccine 2: Date VIS Given
- Should be Empty:

General Vaccine Form

Vaccine Options

Prevnar 20 Eligibility

Shingrix Eligibility

RSV Eligibility

Patient Information

Patient Questions

Patient Live Vaccine Questions

Prevaccination Checklist for COVID-19 Vaccines

What is the FDA’s regulatory framework for COVID-19 vaccination?

Consent