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  • Immunization Consent Form

    Immunization Consent Form

    Please have your pharmacy insurance card ready when completing
  • Format: (000) 000-0000.
  • Date of Birth
     / /
  • Gender*
  • Ethnicity
  • Race
  • Vaccine to receive?*

  • The following questions will help us determine that it is safe to give you the selected vaccines. If you answer "Yes" to any question, you should still be able to receive the vaccine. If a question is not clear, please ask us to explain it.

  • Are you sick today?*
  • Are you allergic to latex?*
  • Do you have any allergies to medications, food, or a vaccine component? (ie. eggs, gelatin, neomycin, Thimerosal, etc.)*
  • Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*
  • Have you ever had a serious reaction after receiving a vaccination or have a history of fainting, particularly with vaccines?*
  • Have you been diagnosed and receiving treatments for rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?*
  • Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder?*
  • Have you had a seizure, brain/other nervous system problem or Guillain Barre?*
  • Have you received any vaccinations or TB skin test in the past 4 weeks?*
  • In the past 3 months, have you taken medications that weaken your immune system response such as steroids (ie. prednisone, cortisone, etc.) or cancer treatments (radiation, oral or injected anticancer drugs)?*
  • Do you take anticoagulation medications (blood thinners)? (ie. warfarin, Coumadin, Eliquis, clopidogrel, etc)*
  • Are you currently taking any antiviral medications? (ie. acyclovir, famciclovir, valacyclovir)*
  • During the past year, have you received a transfusion of blood or blood products or been given immune (gamma) globulin?*
  • For women: Are you pregnant or is there a chance you could come become pregnant during the next month?*
  • Have you tested positive for the Sars2-COV-19 virus (by PCR or antigen test) in the previous 90 days?*
  • Have you been treated with convalescent plasma or monoclonal antibodies in the previous 90 days?*
  • Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?*
  • Have you had a past reaction to gelatin or triple antibiotic ointment?*

  • Consent to Vaccination

    I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hart 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 certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
  • Form completed by:*

  • Pharmacy Use Only

    Do not complete the below questions

  • Insurance Card Information

  • Vaccine(s) to Receive*

  • Abrysvo (Pfizer)

    Respiratory Syncytial Virus (RSV)
  • VIS Date*

  • Covid - 19

  • VIS Date*
  • Vaccine # in Series*
  • Has a sufficient amount of time based to be available for a booster under current CDC guidelines?*

  • Influenza

  • VIS Date*

  • Shingrix (Shingles)

    GlaxoSmithKline
  • VIS Date*
  • Vaccine # in Series*

  • Pneumococcal

  • VIS Date*

  • Energrix (Hepatits B)

    GlaxoSmithKline
  • VIS Date*
  • Vaccine # in Series*

  • Havrix (Hepatitis A)

    GlaxoSmithKline
  • VIS Date*
  • Vaccine # in Series*

  • Adacel (Tdap-Tetanus/Diphtheria/Pertussis)

    Sanofi Pasteur
  • Vaccinator*
  • Other Credentials
  • Reviewer*
  • Vaccination Date*
     / /
  • Should be Empty: