Rockville Centre Pharmacy Vaccine Consent Form

Rockville Centre Pharmacy Immunization Consent Form
30 HEMPSTEAD AVE, SUITE 156, ROCKVILLE CENTRE, NY 11570 TEL (516)764-6161 / FAX (516)678-3246
FULL NAME*
GENDER*
DATE OF BIRTH*

MonthDayYear
Date
PHONE*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What vaccine (s) would you like to receive:

FluFlu 65+Covid ModernaCovid PfizerRSVTDAPShinglesPneumoniaOther
EMERGENCY CONTACT & RELATION
PRIMARY CARE PHYSCIAN NAME AND PHONE NUMBER (IF APPLICABLE) *IN ACCORDANCE TO STATE LAW VACCINE DOCUMENTS WILL BE PROVIDED TO PRIMARY PHYSICIAN

THE FOLLOWING QUESTIONS WILL HELP US DETERMINE WHICH VACCINES MAY BE GIVEN TODAY. IF A QUESTION IS NOT CLEAR, PLEASE ASKYOUR PHARMACIST TO EXPLAIN IT.*

	Yes	No	Don't Know
Are you sick today? (Positive for Covid, Flu, RSV, or illness within the past 7 days)
Do you have any allergies to medications, foods (eggs), latex or any vaccine component?
Have you ever had a serious reaction after receiving a vaccination?
Have you received any vaccinations in the past 4 weeks?
Do you have any neurological disorder such as seizures or other disorders that affect the brain or have had a disorder that resulted from a vaccine?
Do you have cancer, leukemia, AIDS, or any other immune system problem?
Do you take cortisone, prednisone or any other steroid, anti-cancer medication, or have had x-ray treatments?
During the past year have you received a transfusion of blood or blood products, including antibodies?
FOR WOMEN: Are you pregnant or could become pregnant in the next three months?
FOR PATIENTS OVER 65 YEARS OLD OR HAVE A CHRONIC CONDITION SUCH AS ASTHMA OR COPD: Have you received the Pneumococcal or “Pneumonia” vaccine?

I authorize the release of any medical or other information with respect to this vaccine to my health care providers, Medicare, Medicaid or other third party payer as needed and request payment of authorized benefits to be made on my behalf to Rockville Centre Pharmacy.

I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine.

I acknowledge receipt of the pharmacy’s Notice of Privacy Practices for Protected Health Information.

I acknowledge that the administration of an immunization or vaccine does not substitute for an annual check-up with the patient’s primary care physician.

I acknowledge that my vaccination record may be shared with federal or state agencies for registry reporting.

I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area, after the administration of the immunization, for 15 minutes.

I have read or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s).

I fully release and discharge Rockville Centre Pharmacy, its affiliates, their officers, directors, and employees from any liability for illness, injury, loss, or damage which may result therefrom.
Patient Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Rockville Centre Pharmacy Immunization Consent Form

30 HEMPSTEAD AVE, SUITE 156, ROCKVILLE CENTRE, NY 11570 TEL (516)764-6161 / FAX (516)678-3246