*MISC* Vaccination Consent Form Finksburg Pharmacy

Finksburg Pharmacy Vaccination Consent Form

(410) 526-1055 www.finksburgpharmacy.com
Type of Vaccine to be Administered: *Choose ONE* *Separate consent form required for each individual vaccine; multiple vaccinations can be administered on the same day* *

Shingrix (Shingles) - Recommended for ALL individuals aged 50 and older; 2 dose series 2-6 months apart Tdap (Tetanus, Diptheria, and Pertussis) - Recommended 1 booster for ALL individuals every 10 years; plus Recommended 1 dose for each pregnancy; plus Recommended 1 dose for each wound management (see below) Prevnar 13 (Pneumonia) - Recommended for ALL individuals aged 65 and older; Recommended for special situations in individuals aged 19-64 (see below) *Pneumovax 23 administration at least one year after Prevnar* Pneumovax 23 (Pneumonia) - Recommended for ALL individuals aged 65 and older; Recommended for special situations in individuals aged 19-64 (see below) *Prevnar 13 administration at least one year before Pneumovax*
To view the CDC Recommendations for child and adult vaccinations, see below attachment and/or visit the CDC website at:

https://www.cdc.gov/vaccines/schedules/index.html
Please Select an Appointment Date and Time of Arrival: *
Name *

First Name Last Name
Mother's Maiden Name *
Gender *

Female Male Other
Gender
Today's Date: *

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Age
Selected Appointment Date and Time
Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone Number *
Please enter a valid phone number.
Phone Type *
Email *

Confirmation Email Reenter Email Address for Confirmation
Primary Care Provider Information *

I don't have a Primary Care Provider Primary Care Provider Name
Primary Care Provider Phone Number
Please enter a valid phone number.
Screening Questions

If you answer "YES" to any question, it does not necessarily mean you should not be vaccinated. It means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
Do you feel sick or have a fever today? *

Yes No Unsure
Please describe all symptoms you are experiencing today (ex. fever, chills, cough, shortness of breath, headache, vomiting/diarrhea, weakness/fatigue, loss of taste and/or smell, etc.) *
Do you have any chronic (long-term) health conditions? (ex. diabetes, cancer, asthma, COPD, chronic kidney disease, anemia, etc.) *

Yes No Unsure
Please select all of your chronic (long-term) health conditions: *

Anemia Cancer Chronic Kidney Disease COPD (Chronic Obstructive Pulmonary Disease) Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies Immunocompromised state (weakened immune system) from solid organ transplant Sickle Cell disease Smoking Type 2 Diabetes Mellitus Other
Do you have a history of anaphylaxis or anaphylactic (severe allergic) reaction to medications, food, latex, vaccines, etc.? (Ex. eggs, gelatin, thimerosal, etc.) *

Yes No Unsure
Please list what you are severely allergic to here: *
Have you ever had a serious reaction after receiving a vaccination or other injectable medication? *

Yes No Unsure
Please describe your reaction here: *
Are you pregnant (or think you may become pregnant in the next month) or breastfeeding? *

Yes No Unsure
Have you received another vaccine in the past 4 weeks? 12 months? *

Yes No Unsure
Please list all recent vaccinations below with approximate date of administration: *
Do you take cortisone, prednisone, other steroids, anticancer drugs, or have you had x-ray treatments? *

Yes No Unsure
Cancer
Chronic Kidney Disease
COPD
Heart Conditions
Immunocompromised - Solid Organ Transplant
Anemia
Sickle Cell Disease
Smoking
Type 2 Diabetes
Do you have a weakened immune system caused by a medical condition (ex. HIV/AIDS, cancer, etc.) or immunosuppressive drug therapy? *

Yes No Unsure
Please list medical conditions and/or immunosuppresive drug therapy here: *
During the past year, have you received a blood transfusion or blood products, or been given a medicine called immune globulin? *

Yes No Unsure
Insurance/Payment Information
Insurance Type: Please upload a picture of the front and back of your insurance card below if possible to ensure smooth data entry and processing. *

Private Insurance Medicare Medicaid/Medical Assistance No Insurance
Private Insurance Information:

RX BIN #   # # # # # #*
RX PCN #  *
RX Group #   *
RX ID #   *
Medicare ID #   XXXX - XXX - XXXX*
*Note: This is your NEW Medicare Unique ID number.

Effective Date   *
Last 4 digits of Social Security Number (for Medicare ID verification) *
Medical Assistance # (11 digits long): ###########*
FRONT of Insurance Card *please use a light colored background in picture*

This is not required, but will ensure that there will be fewer issues with patient and vaccine processing.
Cancel of
BACK of Insurance Card *please use a light colored background in picture*

This is not required, but will ensure that there will be fewer issues with patient and vaccine processing.
Cancel of
CONSENT

*Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. Persons who are allergic to products containing thimerosal (contact lens solution) should be informed that the amount found in certain vaccines have not shown to cause a reaction; however, the severity of the allergy should be investigated before vaccine is given. I consent to the staff to administer the vaccination(s) mentioned below. I have reviewed the vaccine information sheet(s) and understand the benefits and risks of receiving this medication and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations and their officers and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this medication. I agree to wait near the vaccination area for approximately 15 minutes so that I may receive treatment if I begin to feel unwell.
Signature: *

Use your mouse or touchscreen to electronically sign your name. Clear
Please bring your Driver's License (or other form of valid photo ID) to your appointment for proof of identity.
Should be Empty: