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Immunization Consent Form
Please have your pharmacy insurance card ready when completing
Patient Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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District of Columbia
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Hawaii
Idaho
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Date of Birth
/
Month
/
Day
Year
Date
Gender
*
Female
Male
Ethnicity
Non-Hispanic/Latino
Hispanic/Latino
Race
American Indian or Alaska Native
Black or African American
Arabic
Native Hawaiian or Pacific Islander
Asian
White
Back
Next
Vaccine to receive?
*
Abrysvo (RSV)
Covid - 19 (Initial or Booster)
Flu Vaccine (Influenza)
Pneumovax 23 (Pneumococcal)
Engerix-B (Hepatitis B)
Prevnar 13(Pneumococcal)
Havrix (Hepatitis A)
Prevnar 20 (Pneumococcal)
Shingrix (Shingles)
Tdap (Tetanus/Diphtheria/Pertussis)
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?
*
Yes
No
Are you allergic to latex?
*
Yes
No
Do you have any allergies to medications, food, or a vaccine component? (ie. eggs, gelatin, neomycin, Thimerosal, etc.)
*
Yes
No
What are you allergic to?
Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
*
Yes
No
Have you ever had a serious reaction after receiving a vaccination or have a history of fainting, particularly with vaccines?
*
Yes
No
Have you been diagnosed and receiving treatments for rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?
*
Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder?
*
Yes
No
Have you had a seizure, brain/other nervous system problem or Guillain Barre?
*
Yes
No
Have you received any vaccinations or TB skin test in the past 4 weeks?
*
Yes
No
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)?
*
Yes
No
Do you take anticoagulation medications (blood thinners)? (ie. warfarin, Coumadin, Eliquis, clopidogrel, etc)
*
Yes
No
Are you currently taking any antiviral medications? (ie. acyclovir, famciclovir, valacyclovir)
*
Yes
No
During the past year, have you received a transfusion of blood or blood products or been given immune (gamma) globulin?
*
Yes
No
For women: Are you pregnant or is there a chance you could come become pregnant during the next month?
*
Yes
No
Have you tested positive for the Sars2-COV-19 virus (by PCR or antigen test) in the previous 90 days?
*
Yes
No
Have you been treated with convalescent plasma or monoclonal antibodies in the previous 90 days?
*
Yes
No
Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?
*
Yes
No
Have you had a past reaction to gelatin or triple antibiotic ointment?
*
Yes
No
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:
*
Self
Caregiver
Pharmacy Employee (Phone/In-Person)
*
First Name
Last Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)
*
Pharmacy Use Only
Do not complete the below questions
Insurance Card Information
ID Number
Group Number
BIN
PCN
Vaccine(s) to Receive
*
Abrysvo (RSV)
Covid - 19
Influenza
Pneumococcal
Havrix (Hep A)
Shingles
Tdap
Energrix (Hep B)
Abrysvo (Pfizer)
Respiratory Syncytial Virus (RSV)
Lot #
*
Site of Administration
*
Please Select
LD
RD
Expiration Date
*
VIS Date
*
7/24/2023
Other
Covid - 19
Vaccine Mfr
*
Please Select
Janssen / J & J
Moderna
Pfizer-BioNTech (Comirnaty)
Site of Administration
*
Please Select
LD
RD
Lot #
*
Expiration Date
*
VIS Date
*
10/19/2023
5/5/2022 (JNS)
6/17/2022 (MOD)
11/22/2022 (PFZ)
Other
Vaccine # in Series
*
1st
2nd
Booster
Has a sufficient amount of time based to be available for a booster under current CDC guidelines?
*
Yes
No
Influenza
Vaccine (Mfr)
*
Please Select
Afluria (Seqirus Inc.)
Fluad (Seqirus Inc.)
Fluarix (GlaxoSmithKline)
Flublok (Sanofi Pasteur Inc.)
Flucelvax (Seqirus Inc.)
FluLaval (GlaxoSmithKline)
Fluzone (Sanofi Pasteur Inc.)
Fluzone High Dose (Sanofi Pasteur Inc.)
Site of Administration
*
Please Select
LD
RD
Lot #
*
Expiration Date
*
VIS Date
*
8/6/2021
Other
Shingrix (Shingles)
GlaxoSmithKline
Lot #
*
Expiration Date
*
Site of Administration
*
Please Select
LD
RD
VIS Date
*
2/4/2022
10/30/2019
Other
Vaccine # in Series
*
1st
2nd
Pneumococcal
Vaccine Version (Mfr)
*
Please Select
Pneumovax 23 (Merck & Co., Inc.) (10/30/2019)
Prevnar 20 (Pfizer) (5/12/2023)
Vaxneuvance 15 (Merck) (5/12/2023
Prevnar 13 (Pfizer) (5/12/2023)
Site of Administration
*
Please Select
LD
RD
Lot #
*
Expiration Date
*
VIS Date
*
2/4/2022 (P13 / P20)
10/30/2019 (P23)
8/6/2021
5/12/2023 (P13 / P15 / P20)
Other
Energrix (Hepatits B)
GlaxoSmithKline
Lot #
*
Expiration Date
*
Site of Administration
*
Please Select
LD
RD
VIS Date
*
5/12/2023
10/15/2021
Other
Vaccine # in Series
*
1st
2nd
3rd
Havrix (Hepatitis A)
GlaxoSmithKline
Lot #
*
Expiration Date
*
Site of Administration
*
Please Select
LD
RD
VIS Date
*
10/15/2021
Other
Vaccine # in Series
*
1st
2nd
Adacel (Tdap-Tetanus/Diphtheria/Pertussis)
Sanofi Pasteur
Lot #
*
Expiration Date
*
Site of Administration
*
Please Select
LD
RD
VIS Date
*
8/6/2021
Other
Vaccinator
*
Sarah Priestle PharmD
Eric Gillespie PharmD
Miriam Hart BS
Rachel Dalsky CPhT
Kendra Beitzel CPhT
Timothy Rinear CPhT
Other
Other Credentials
PharmD
Pharmacy Intern
BS
CPhT
Reviewer
*
Sarah Priestle
Eric Gillespie
Kendra Beitzel
Rachel Dalsky
Timothy Rinear
Caroline Klug
Elizabeth Slatt
Nicholas Paff
Other
Vaccination Date
*
/
Month
/
Day
Year
Date
Signature of Reviewer
*
Submit
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