Flu Vaccine Appointment & Consent
We provide the Flu Vaccine for individuals age 10 and over, including the High Dose Influenza for age 65 and over. Please complete this form to schedule an appointment. The appointment is not set until the form is completed and submitted.
Which vaccine do you want to receive at this appointment?
*
Please Select
Influenza (regular dose)
High Dose Influenza (Age 65 and over)
High Dose Flu Appointment. Select an appointment time (Your selection for an appointment is not set until you complete and submit the entire consent form below.)
Regular Flu Appointment. Select an appointment time (Your selection for an appointment is not set until you complete and submit the entire consent form below.)
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Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Email (to receive notification of appointment and informational documents)
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Age
AGE
A parent or guardian must be present during the vaccine appointment for any patient under age 18.
Check box
Check this box to indicate that a parent or guardian will be present during the entire vaccine appointment and will sign the consent form.
Race
*
Please Select
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other Race
Required by California Department of Public Health
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Required by California Department of Public Health
Vaccine Recipient Phone Number
*
Mother's First Name
*
Required for proper vaccine documentation
Primary Care Provider Name
If you would like to have a copy of this record sent to your Primary Care Provider, please provide name here.
Influenza Vaccine Screening Questions (If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional information may be necessary before vaccination.)
Yes
No
1. Are you allergic to eggs or any component of the influenza vaccine?
2. Have you ever had a serious reaction to the influenza vaccine?
3. Have you had Guillain-Barre Syndrone, a condition that causes paralysis?
4. Are you pregnant or planning to become pregnant n the next 3 months?
Consent (check each box below after reading and prior to signing the form)
*
Check each box
I agree to stay in the vaccine administration area if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I acknowledge that my immunization information from this visit will be sent to the California Immunization Registry unless I choose to opt out.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hendricks Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).
I have read and reviewed the Notice of Privacy Practices available at www.HendricksPharmacy.com/NOPP.
Insurance (Many insurance plans cover the Flu vaccine with no cost to the member.)
*
Yes
No
Do you have pharmacy insurance (examples include Medicare, Medi-Cal, or private health policies. We are not able to bill Kaiser for flu vaccines)?
Type of insurance
Please Select
Medicare
Medi-Cal
Private/Other
Please select the type of prescription insurance that you have. (Please note that we are not able to bill Kaiser for flu vaccines. You are welcome to pay out of pocket with us if you have Kaiser.)
Insurance ID#
Please enter the ID# from your insurance card (Medicare, Medi-Cal, or Private/Other).
The Flu vaccine is available no matter if insured or uninsured. Since you indicated you have insurance, please read and check this box.
Check box
If INSURED, check this box attesting to bringing in your prescription insurance card for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization and you understand that if the vaccine is not covered by your insurance or the pharmacy is not able to bill your insurance, you will be required to pay for the vaccine upon arrival to your appointment.
The Flu vaccine is available no matter if insured or uninsured. Since you indicated you do not have insurance, please read and check this box.
Check box
If UNINSURED, you must check this box to attest that you understand that you will be charged for the vaccine upon arrival to your appointment.
Full Name
Date/Time
CurrentDate
-
Month
-
Day
Year
Date
Submit Consent Form (required)
Should be Empty: