LTC Vaccination Consent for Vaccines

  • LTC-Facility Pre-Vaccination Checklist for COVID-19 Vaccines

    For vaccine recipients: The following questions will help us determine if there is any reason you should not get a vaccine. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked.
  • Which Vaccine(s)do you need?(Select multiple if needed)*
  • Format: (000) 000-0000.
  •  - -
  • Sex*
  • Billing option:*

  • 1. Are you sick today or have a fever?*
  • 2. Do you have any allergies to medications, food, eggs, yeast, vaccine components or latex?*
  • 3. Have you ever had a serious allergic reaction after receiving a vaccine (including a previous dose of the COVID-19vaccine)?*
  • 4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*
  • 5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease, herpes, or cold sores?*
  • 6. 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?*
  • 7. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?*
  • 8. 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?*
  • 9. For women: Are you pregnant or is there a chance you could become pregnant during the next month?*
  • 10. Have you received any vaccinations or a TB skin test in the past 4 weeks?*
  • 11. Do you have a history of fainting, particularly with vaccines?*
  • 12. In the past 14 days have you had contact with a confirmed COVID-19 patient?*

  • I certify that I am: (a) the patient and at least 12 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Torrance Pharmacy or its agents to administer the COVID-19 vaccine.

    I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 12 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.

    I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.

    I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.

    On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Torrance Pharmacy, and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.

    I acknowledge that: Post Vaccination the pharmacy must submit Vaccine Administration Data through the immunization information System(IIS) of state jurisdiction within 72 hours after administration and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.

    I further authorize Torrance Pharmacy or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to Torrance Pharmacy or its agents with respect to the above requested items and services. 

    I acknowledge receipt of the Notice of Privacy Rights.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  •  - -

  • Name of EUA fact sheet or VIS provided:

    Moderna   J&J  Pfizer  Pneumonia    Shingles   Influenza

    Date Provided:

    Dose given:

    0.5 ml  0.3 ml  0.7 ml
    Route: IM

    Site:

    Left Deltoid  Right Deltoid

    Pharmacist:

    Date vaccine given:

  • Should be Empty: