Immunization Consent Form - CSRX Pharmacy

Immunization Consent Form

Please have your pharmacy insurance card ready when completing
Insurance Card Information

Please input each of the following for your insurance card
Bin number
PCN
Rx Group
Identification Number
Patient Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Age *
Gender *

Female Male
Patient Phone Number *
Vaccine(s) to receive? *

Influenza Shingles (Shingrix) Tetanus (Td) Tetanus/Pertussis (Tdap - whooping cough) Pneumonia (Prevnar or Pneumovax) Other
Primary Care Provider (PCP) Name

First Name Last Name
For Patients: The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.
Are you sick today? *

Yes No
Do you have any allergies to medications, food, eggs, yeast, latex, or a vaccine component? *

Yes No
Have you ever had a serious reaction after receiving a vaccination? *

Yes No
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
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders? *

Yes No
Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores? *

Yes No
In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? *

Yes No
Have you had a seizure, brain/other nervous system problem or Guillain Barre? *

Yes No
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug (including acyclovir, famciclovir, valacyclovir)? *

Yes No
Have you received any vaccinations or TB skin test in the past 4 weeks? *

Yes No
Do you have a history of fainting, particularly with vaccines? *

Yes No
For women: Are you pregnant or is there a chance you could come become pregnant during the next month? *

Yes No N/A
For Tdap and adult Td: Do you have a cut, injury, puncture or open would that prompted you to get a tetanus shot? *

Yes No N/A
For Shingles (Zoster) vaccine: Have you had a past reaction to gelatin or triple antibiotic ointment? *

Yes No N/A
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 Duvall Family Drugs, 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 *

First Name Last Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)

Clear
Pharmacy Use Only

Do no complete the below questions
Signature of Pharmacist
Signature/Title of Immunization Administrator
Should be Empty:

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