Immunization Consent Form

Immunization Consent Form

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.
PATIENT'S LAST NAME
PATIENT'S FIRST NAME
ADDRESS
CITY
STATE
ZIP CODE
10-DIGIT PHONE NUMBER
GENDER
MALE OR FEMALE
BIRTHDATE
MM/DD/YYYY
PRIMARY CARE PHYSICIAN

The following questions will help us determine your eligibility to be vaccinated today.

	YES	NO
1. ARE YOU FEELING SICK TODAY?
2. DO YOU HAVE ANY ALLERGIES TO MEDICATIONS, FOOD OR VACCINES?
3. HAVE YOU EVER HAD A SERIOUS REACTION AFTER RECEIVING A VACCINATION?
4. DO YOU HAVE ANY LONG-TERM HEALTH PROBLEMS WITH HEART DISEASE, LUNG DISEASE, ASTHMA, KIDNEY DISEASE, NEUROLOGIC OR NEUROMUSCULAR DISEASE, LIVER DISEASE, METABOLIC DISEASE(EG DIABETES), ANEMIA, OR OTHER BLOOD DISORDERS?
5. HAVE YOU EVER FELT FAINT OR DIZZY AFTER RECEIVING A VACCINE?
6. DO YOU HAVE CANCER, LEUKEMIA, AIDS, OR ANY OTHER IMMUNE SYSTEM PROBLEMS?
7. HAVE YOU HAD GUILLAIN-BARRE SYNDROME, A SEIZURE, BRAIN OR NERVE PROBLEM?
8.DURING THE PAST YEAR HAVE YOU RECEIVED A TRANSFUSION OF BLOOD OR BLOOD PRODUCTS, OR BEEN GIVEN A MEDICATION CALLED IMMUNE (GAMMA) GLOBULIN?
9. ARE YOU CURRENTLY ON HOME INFUSIONS OR WEEKLY INJECTIONS?
10. HAVE YOU RECEIVED ANY VACCINATIONS OR SKIN TEST IN THE PAST 4 WEEKS?
11. ARE YOU ALLERGIC TO EGGS?
12. ARE YOU ALLERGIC TO LATEX?
13. FOR WOMEN: ARE YOU PREGNANT OR IS THERE A CHANCE YOU COULD BECOME PREGNANT DURING THE NEXT 3 MONTHS?
14. IN THE PAST 3 MONTHS, HAVE YOU OR ANYONE IN YOUR HOUSEHOLD TAKEN CORTISONE, PREDNISONE, OTHER STEROIDS, HIGH-DOSE METHOTREXATE, AZATHIOPRINE, 6-MERCAPTOPURINE, ANTIVIRALS, ANTICANCER DRUGS, OR HAVE YOU HAD ANY RADIATION TREATMENTS?

ADVERSE REACTIONS
A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of any vaccine causing serious harm, or death, is extremely small. Local symptoms may include: sight tenderness redness, itching or swelling at the site of injection. Systemic symptoms may include: fever, malaise and muscle pan. Other systemic symptoms may occur infrequently. These reactions usualy begin 6 to 12 hours after immunization and can persist for a few days. Immediate presumable allergic reactions such as hives, angioedema, allergic asthma or systemic anaphylaxis occur rarely after immunizations. These reactions may result from from hypersensitivity reactions in people with severe egg allergy, and such people should not be given certain vaccines that contain eggs. People with documented immunoglobulin E (IgE)-mediated hypersensitivities to eggs or other vaccine components, including thimerosal, may also be at increased risk of reactions from inmunizations. In the case of a severe reaction such as high fever, behavior changes or fu like symptoms that occur after vaccination, see a doctor right away. Signs of an allergic reaction can indude dificulty breathing hoarseness or wheezing hives, paleness, weakness a fast heartbeat, or dizziness within a few minutes to few hours after the shot.
CONSENT
I have read the adverse reactions associated with the administration of vaccines. A copy of the vaccine information sheet has been provided to me and a copy of the vaccine manufacture's drug information sheet is available on request. Furthermore, I have also had an opportunity to ask questions about these immunizations. I believe the beneits outweigh the risks and voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization(s) or the receipt of the immunization(s) by the person named below for whom I am the legal guardian ("WARD"). My medical record may be shared with my physician or other healthcare provider and the medical record of my Ward may be shared wth his/her physician or other healthcare provider. I am requesting that the immunization(s) be given to me or my directors, contractors, agents and employees (collectively Released Parties"), from any and all claims arising out of, in connection with or in any way related to my receipt and the receipt by my injury, death or damaged suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described above. Nowell Pharmacy will use and disclose your personal and health information or personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we described and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies in regard to you and your Ward's personal health information. I acknowledge that have received a copy of the Notice of Privacy Practices."
SIGNATURE /LEGAL GUARDIAN

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Immunization Consent Form

ADVERSE REACTIONS

CONSENT