Edgewood Pharmacy’s Vaccination consent form
Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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-
Area Code
Phone Number
Please upload Prescription card or Medicare part b cards in field below
Vaccine(s) to receive?
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Influenza
Shingles (Shingrix)
Tetanus (Td)
Tetanus/Pertussis (Tdap - whooping cough)
Hepatitis A
Hepatitis B
Pneumonia (Prevnar or Pneumovax)
Primary Care Provider (PCP) Name
First Name
Last Name
PCP Phone Number
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Area Code
Phone Number
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? If unsure, speak to the pharmacist
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Yes
No
Do you have any allergies to medications, food, latex, or a vaccine component?
*
Yes
No
Have you ever had a serious reaction after receiving a vaccination?
*
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?
*
Yes
No
Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
*
Yes
No
Have you had a seizure, brain, or other nervous system problem?
*
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?
*
Yes
No
Have you received any vaccinations in the past 4 weeks?
*
Yes
No
Consent to Vaccination
I hereby claim that the above information is true and correct to the best of my knowledge. I consent that pharmacists affiliated with [XXX] Pharmacy may administer this vaccine. I have been informed of the risks and benefits of the vaccine via the CDC-issued Vaccine Information Statement (VIS). I give permission to [XXX] Pharmacy to seek compensation through my insurance, if applicable, knowing that my insurance may not fully cover the associated costs of the vaccine and administration. If this occurs, I understand that I am fully responsible for all costs associated with the administration of the vaccine. I also give consent to have this vaccine information shared as necessary with appropriate parties, including my healthcare provider and the immunization registry, [State] Statewide Immunization Information System.
Date
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Date
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