Vaccine Consent Form
Bring any form of ID and insurance card to your appointment
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of your Doctor
First Name
Last Name
Doctors Phone Number
Please enter a valid phone number.
ATTENTION:
If you are pregnant and would like to sign up for an RSV vaccine, a prescription is REQUIRED that MUST contain the number of weeks you are into your pregnancy (Must be done weeks 32-36 of pregnancy).
Type of Vaccine (CAN SELECT MORE THAN 1 VACCINE)
*
Fluad (FLU VACCINE 65 years of age and older)
Flucelvax (FLU VACCINE 5-64 year old)
Shingrix (SHINGLES VACCINE 50 years of age and older)
Prevnar 20 (PNEUMOCOCCAL VACCINE 65 years of age and older)
Prevnar 20 (PNEUMOCOCCAL VACCINE 19 - 64 year old with chronic conditions)
ABRYSVO (RSV VACCINE - 60 years of age and older; Pregnant women: Weeks 32-36)
TWINRIX (HEPATITIS A & HEPATITIS B VACCINE - 18 years of age and older)
BOOSTRIX (TDAP - 10 years of age and older)
Is this for an upcoming clinic (school, facility, etc) or a regular pharmacy appointment?
*
Clinic
Pharmacy
Which arm would you like to receive your vaccine in today?
*
Left Arm
Right Arm
Appointment
*
Are you feeling sick today?
*
Yes
No
Do you have any health conditions, such as heart disease, diabetes or asthma?
*
Yes
No
Please indicate your health conditions below
Do you have allergic reaction to medications, food, or any ingredients or materials used with vaccine (i.e. aluminum, eggs, bovine protein, gelatin, neomycin, gentamicin, latex,polymyxin, thimerosal, preservatives, etc.)?
*
Yes
No
Please indicate below
Have you ever had a serious reaction after receiving a vaccination, such fainting or feeling dizzy?
*
Yes
No
Have you ever had a seizures, brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?
*
Yes
No
Have you received any vaccinations or skin tests in the past 4-8 weeks?
*
Yes
No
Please list below
Are you currently on home infusions, weekly injections, anticancer drugs or radiation treatments?
*
Yes
No
Are you currently taking high-dose steroid therapy for longer than 2 weeks?
*
Yes
No
Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in the Yes No Don’t knowpast year?
*
Yes
No
Have you had yellow fever?
*
Yes
No
Do you have a history of thymus disease or had your thymus removed?
*
Yes
No
Don't know
Do you have a history of thrombocytopenia or thrombocytopenia purpura?
*
Yes
No
Don't know
Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days?
*
Yes
No
Are you pregnant or planning to be pregnant in the next 30 days
*
Yes
No
Has your child had wheezing or asthma in the past 12 months?
*
Yes
No
Have you had a shingles vaccination or been diagnosed with shingles in the last 12 months?
*
Yes
No
Have you ever had a pneumococcal vaccination?
*
Yes
No
Insurance Information
*
I have medicare
Commercial insurance
I do not have insurance
Please upload an image of the front of your Prescription Insurance card here:
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of
Please upload an image of the front of your Medical Insurance card here:
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(If applicable) Please upload an image of the front of your Medicare/Aetna Medicare/Part B insurance card here:
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of
Medicare Number (red, white, and blue card)
I hereby give my consent to the administering of the flu vaccine as specified to the choice above. I acknowledge the risks and benefits in administering of the vaccine. I likewise understand that such risks of having side effects or complications associated with the receiving of the vaccine cannot be predicted. I have been advised to stay in the facility for at least 15 minutes after the vaccine has been given to me for observation. I hereby release and hold harmless the facility, its staff, agents, employees, successors, affiliates, subsidiaries, directors, and officers from any and all liabilities or claims whether known or unknown arising from, or in connection with the administration of the vaccine listed above. I authorize the disclosure of my information for the purpose of necessary processing, recording of my information relevant to the administering of the vaccine including claims for costs and fees. I agree to be responsible for any financial cost-sharing amounts, including copays, coinsurance, and other deductibles including those which are not covered by my insurance benefits.
Age of Consent
I hereby declare that I am of legal age and I give my consent with full knowledge and responsibility to the risks and benefits of the vaccine. I have had the opportunity to ask questions and which answers were given to me to my satisfaction.
I am the legal representative of the above-named patient. The patient is of legal age and I am executing this document on his/her behalf. He/she have had the opportunity to ask questions and which the answers were provided to him/her to his/her satisfaction.
I am the legal guardian of the above-named patient. I am executing this document on his/her behalf with my full consent and authority. I have had the opportunity to ask questions and by which answers were given to me to my satsifaction.
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: