Influenza Vaccine Consent Form

1
Appointment
2
Appointment Date
Date
Year
Month
Day
3
Patient Name* This field is required.
First Name
Middle Initial
Last Name
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Age* This field is required.
6
Gender* This field is required.
Female
Male
7
Patient Phone Number* This field is required.Please provide the phone number Uptown Pharmacy should call with any questions about your form submission
Area Code
Phone Number
8
EmailPlease provide the email where you would like your appointment information sent.
example@example.com
9
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Choose a payment method* This field is required.
My insurance is already on file with Uptown Pharmacy
I Pay out of Pocket for my vaccines
Commercial Insurance / Private Insurance
Medicare Part B
11
Bin number
12
Insurance company name:
13
PCN
14
Rx Group
15
Identification Number
16
Please Indicate any allergies the patient has:
No Known Allergies
Penicillin/Amoxicillin
Cephalosporins
Sulfa
Erythromycin
Tetracycline/Doxycyline/Minocyline
Morphine
Codeine
Oxycodone
Aspirin
NSAIDs (Ibuprofen, Naproxen, Meloxicam, Diclofenac, etc)
Latex
Preservatives
A previous vaccination (please list which vaccine in other box below)
Other
17
Vaccine(s) you would like to schedule to receive?* This field is required.
Influenza
Influenza High Dose (age 65 or above)
Shingrix Shingles vaccine (age 50 or above, 2 dose series given once)
Prevnar-20 Pneumonia Vaccine (age 65 or above or with certain other medical conditions given once, one booster may be needed after age 65)
RSV (Respiratory Syncytial Virus) Vaccine (approved for age 60 and over, give once, no booster needed)
Tdap (Tetanus Diptheria and Pertussis) (age 18 and over- recommended every 10 years)
Spikevax (Moderna) COVID-19 2024-25 Vaccine
Comirnity (Pfizer) COVID-19 2024-25 Vaccine
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Primary Care Provider (PCP) Name
First Name
Last Name
19
Are you sick today?* This field is required.
Yes
No
20
Do you have any allergies to medications, food, eggs, yeast, latex, or a vaccine component?* This field is required.
Yes
No
21
Have you ever had a serious reaction after receiving a vaccination?* This field is required.
Yes
No
22
Do you have a history of fainting, particularly with vaccines?* This field is required.
Yes
No
23
Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?* This field is required.
Yes
No
24
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?* This field is required.
Yes
No
25
Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, herpes, or cold sores?* This field is required.
Yes
No
26
In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?* This field is required.
Yes
No
27
Have you had a seizure, brain/other nervous system problem or Guillain Barre?* This field is required.
Yes
No
28
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug (including acyclovir, famciclovir, valacyclovir)?* This field is required.
Yes
No
29
For women: Are you pregnant or is there a chance you could come become pregnant during the next month?* This field is required.
Yes
No
N/A
30
For COVID: Do you have a history of myocarditis or pericarditis, multi-system inflammatory syndrome, or blood clots?* This field is required.
Yes
No
31
For Tdap an dadult Td: Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?* This field is required.
Yes
No
32
For Zoster (Shingles): Have you had a past reaction to gelatin or triple antibiotic ointment?* This field is required.
Yes
No
33
Form completed by* This field is required.
First Name
Last Name
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Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old, or Medical Power of Attorney). You can sign using your touch screen, or by clicking and holding your mouse button. By signing you agree to the Consent to Vaccination. I have read or have had explained to me the information in the important information statement about influenza vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of influenza vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request. FOR MEDICARE & INSURANCE RECIPIENTS: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment.
Clear
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Date
Date
Month
Day
Year
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Reminder Date
Date
Year
Month
Day
Should be Empty: