Vaccine Consent Form

Vaccination Appointments

We currently offer Flu, Shingles, Pneumonia, and Tetanus/Diphtheria/Pertussis vaccines. Most insurances are accepted as well as out of pocket payment for vaccines. Vaccinations are offered between the hours of 9AM and 5PM.
Terms and Conditions

Please ensure the form is filled out as completely as possible to save time when you arrive. Any applicable payment or copayment is due before a vaccine will be administered.
Name

First nameLast name
Date of birth

MonthDayYear
Date
Age
Gender

FemaleMale
Phone

Area CodePhone Number
Address

Home address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Email address
example@example.com
Doctor/primary care provider name
I want to receive the following vaccination(s):
Options: Flu, Pneumonia, Shingles, Tdap
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The following questions will help us determine your eligibility to be vaccinated today.

All Vaccines

	Yes	No	Don't Know
1. Do you feel sick today?
2. Do you have any health conditions, such as heart disease, diabetes or asthma?
3. Do you have allorgies to latox, modications, food or vaccines (examplos: ogge, bovine protoin, golatin, gontamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?
4. Have you ever had a reaction after receiving a vaccination, including lainting or feeling day?
5. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guilain-Barre syndrome (a condition that causes paralysis) or other nervous system problem?
6. For women: Are you pregnant or considering becoming pregnant in the next month?
7. Have you received any vaccinations or skin tests in the past four to eight weeks?
8. Do you have a condition that may woakon your immune systom (o.g., cancor, loukomic, lymphoma HM/AIDS, transplant)
9. Are you currently on home infusions, weekly injections such as Humira* (adalimumab), Remicade (inflodmab) or Enbrel* (etanercepthigh-dose methotrexate, azathioprine or 6-mercaptopurine, antivirais, anticancer drugs or radiation treatments?
10. Are you currently taking high-dose steroid therapy (prednisone > 20mg/day or equivalent) for longer than 2 weeks?
11. Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in the past year?
12. Do you have a history of thymus disease (including myasthonia gravis, DiGeorge syndrome or thymoma) or had your thymus removed?
13. Do you have a history of thrombocytopenia or thrombocytopenia purpura?

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I certify that I am:(a) the patient and at least 18 years of age;(b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, hereby give my consent to the healthcare provider of Nowel Pharmacy, as applicable (each or "applicable Provider" administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have selected to receive. I consent to inclusion of this immunization data in the New Mexico Immunization Registry for myself or on behalf of the person named above.
Patient signature

Clear
Date

MonthDayYear
Date

Vaccination Appointments

Terms and Conditions

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