IMMUNIZATION CONSENT FORM

Schedule your Appointment Date & Time

Name

First NameLast Name

Date of Birth

Date

Age

Sex at Birth

Address

Street Address Line 2

CityState

Zip

Medicare ID ("Red White and Blue Card" If applicable)

Phone number

Format: (000) 000-0000.

Emergency Contact Name

Emergency Contacts Phone number

Format: (000) 000-0000.

Primary Care Doctor

The pharmacy will attempt to notify your primary care provider within 72 hours of administering a vaccination.

Do you take any medications every day? If yes, please list

Primary Care Doctor Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Please select which vaccine you would like to receive

If you would like to receive a second vaccine, please select below. If you would like to receive more than two vaccines we typically reccomend booking a second appointment at a later date.

Precautions and Contraindications: Please mark YES OR NO for each question.

Rows	Yes	No
1.) Are you 18 years of age or older?
2.) Do you have a cold, fever, or acute illness?
3.) Do you have any allergies to medications, food, or any Vaccine? If Yes, please list in form below
4.) Are you allergic to chicken eggs or egg product?
5.) Are you allergic to thimerosal (cleaning products or contact lens solution)?
6.) Have you ever had a serious reaction after receiving a vaccination?
7.) Have you ever been diagnosed with Guillain-Barre’ syndrome?
8.) Do you have seizure, brain, or nerve problem?
9.) Have you received any vaccinations in the past 4 weeks?
10.) Have you had this vaccine (or a dose in the same series) before? If yes, when:

If you selected yes to question number 3 above please list your allergies: blanks

If you selected yes to question 10 please list date here:

Date

I voluntarily request that a pharmacist employed by Palms Pharmacy give me the vaccine(s) (“Vaccine”) selected above. Palms Pharmacy pharmacists give vaccines under a collaborative practice agreement with a licensed physician. I received a copy of the Vaccine Information Statement (VIS), which explains the benefits and possible side effects of the Vaccine. I read it, and the pharmacist answered my questions. I answered the health questions above truthfully. I understand that a “Yes” answer may increase my chance of a reaction, and after considering this, I choose to receive the Vaccine. I authorize Palms Pharmacy to bill my insurer for this service and to receive the payment. I will pay any copay, coinsurance, deductible, or cost not covered by my insurance. I authorize Palms Pharmacy to use and share my information as needed to provide my care and receive payment, including with my insurer, Medicare, Medicaid, pharmacy benefit managers, my doctor, regulatory agencies, and the Florida immunization registry (Florida SHOTS). To the extent allowed by law, I release Palms Pharmacy, its pharmacists, employees, and contractors from any claims related to my receipt of the Vaccine. By signing below, I certify that I am the patient or the patient’s parent, guardian, or legal representative, and that I have read, understand, and agree to the statements on this form.

Signature of Patient or Legal Guardian

If the person signing above is not the person receiving the immunization, please indicate your relation to the patient.

Type a question