Consent Form and Screening Questionnaire for General Immunizations
This form is NOT for scheduling COVID-19 vaccines.
Patient's Full Name (First MI Last)
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Address
*
Address
Street Address Line 2
City
State
Zip Code
Phone
*
Gender
*
Male
Female
Email Address
example@example.com
Primary Care Doctor
Doctor City/State
Which school do you work at/does your child attend?
Please Select
South Hardin High School
South Hardin Middle School
Eldora-New Providence Elementary
Hubbard-Radcliffe Elementary
Would you like us to check your eligibility for other vaccines?
*
Yes
No
Which vaccine are you wanting to receive? Check all that apply.
Flu
Shingles
Pneumonia
Tdap
Other
Questionnaire
Do you feel sick today?
*
Yes
No
Don't Know
Do you have any allergy to medications foods, or any vaccines? Eggs, gelatin, thimerosal, neomycin, gentamicin, latex, baker's yeast, aluminum, preservatives, etc.
*
Yes
No
Don't Know
Please specify allergy:
*
Have you ever had a serious reaction or fainted after receiving any vaccination?
*
Yes
No
Don't Know
Have you ever had a seizure disorder, brain disorder, or Guillain-Barre Syndrome?
*
Yes
No
Don't Know
FOR WOMEN: Are you pregnant or are you planning on becoming pregnant during the next month?
Yes
No
Don't Know
For children ages 2-4: Has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?
*
Yes
No
Don't Know
For those 50+: Have you had a shingles vaccination or been diagnosed with shingles in the last 12 months?
*
Yes
No
Don't Know
For those 65+: Have you ever had a pneumococcal vaccination?
*
Yes
No
Don't Know
For children/teens: Has the child, sibling, or parent had a seizure; has the child had brain or other nervous system problems?
*
Yes
No
Don't Know
Do you have a long-term health problem with heart, lung, kidney, diabetes, asthma, no spleen, cochlear implant, anemia or a blood/bleeding disorder?
*
Yes
No
Don't Know
Please specify health problem:
*
Have you received any immunizations in the past 4 weeks?
*
Yes
No
Don't Know
Please list immunization(s) received:
*
Do you have cancer, leukemia, HIV/AIDS, history of a transplant, or an autoimmune disorder?
*
Yes
No
Don't Know
In the past 3 months, have you taken medications that affect immune system such as prednisone, other steroids, or anticancer drugs, drugs for autoimmune disease (RA, Crohn's etc.), or had radiation?
*
Yes
No
Don't Know
During the past year, have you received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin or an antiviral drug?
*
Yes
No
Don't Know
Signatures
Flu Injection VIS
Flu Mist VIS
Other Vaccine Information Statements can be found by clicking here
Notice of Privacy Practices
Acknowledgements
I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent & Release.
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy & of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Person to Receive Vaccine & VIS
*
Date
*
/
Month
/
Day
Year
Date
Parent/Guardian Name
*
Relationship to patient
*
Insurance Information
*
I hereby authorize the pharmacy to bill my Insurance on my behalf for the immunizations and receive payment
Member #
*
BIN #
PCN #
Submit
Should be Empty: