Vaccine Consent & Assessment

First Name*

MI

Last Name*

Best Phone Number*

Format: (000) 000-0000.

Date of Birth*

Date

Age

Social Security Number*

Weight

Gender

Address

Home Address

Street Address Line 2

CityState

Zip

Primary Care Provider

I want to be protected from the following. Please check the desired vaccinations.

Will you be receiving this vaccination(s) as part of a clinic or group?*

YesNo

If Yes, what is the name of the clinic or group?

1. Are you sick today?

YesNo

2. Do you have allergies to medications, food, a vaccine component, or latex?

YesNo

3. Have you ever had a serious reaction after receiving a vaccination?

YesNo

4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?

YesNo

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?

YesNo

6. In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis,; or have you had radiation treatments?

YesNo

7. Have you had a seizure or a brain or other nervous system problem?

YesNo

8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?

YesNo

9. For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNo

10. Have you received any vaccinations in the past 4 weeks?

YesNo

I hereby give my consent to the pharmacist of Eastridge-Phelps Pharmacy, to administer the vaccine(s) I have requested. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read and/or had explained to me the CDC's Vaccine Information Statement (VIS) on the vaccine(s) I have elected to receive. I have had the opportunitytoaskquestions that were answered to my satisfaction. As with all medical treatment, there is no guarantee that will not experience an adverse reaction from the vaccine or medication. I fully release and hold harmless Eastridge-Phelps Pharmacy, its pharmacists and employees from any and all liabilities or claims arising out of, in connection with, or in any way related to the administration of the vaccine(s) given. I thatthe understandinformation contained on this form may be shared with the Stated Health Division (SHD) and/or state immunization registries, and will remain confidential and will not be released except as permitted or required by law. If eligible, I authorize Eastridge-Phelps Pharmacy to submit a claim for reimbursement on my behalf to Medicare or any other contracted third-party payer. If the will claimisdenied,IunderstandthatIberesponsible for payment. I acknowledge that I have received a copy of the Eastridge-Phelps Pharmacy Notice of Privacy Practices. Furthermore, I agree to remain near the vaccination location for approximately 15-20 minutes after administration for observation by the administering pharmacist.

(Signature of Patient or Parent/Guardian)

Vaccine Consent and Assessment