General Vaccine Screening and Consent Form

Vaccine Screening and Consent Form
Vaccination Times are as follows:

*subject to change

Monday through Friday

10AM to 5PM

Saturday and Sunday

11AM to 4PM

Pneumonia Vaccine
Please Select the Pneumonia Vaccine you would like:*

Pneumovax 23Prevnar 13Prevnar 20

RSV Vaccine
Please Select the RSV Vaccine you would like:*

Arexvy (60 years and older)Abrysvo (Pregnancy between 32-36wks)

Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemalePrefer not to answer
Address*

Street Address

Street Address 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

TdAP - Please review and/or download your Vaccine Information Sheet (VIS)
HPV - Please review and/or download your Vaccine Information Sheet (VIS)
Meningitis - Please review and/or download your Vaccine Information Sheet (VIS)
Flu - Please review and/or download your Vaccine Information Sheet (VIS)
Pfizer - Please review and/or download your Vaccine Information Sheet (VIS)
Moderna - Please review and/or download your Vaccine Information Sheet (VIS)
MMR - review and/or download your Vaccine Information Sheet (VIS)
Shingles - Please review and/or download your Vaccine Information Sheet (VIS)
Varicella - Please review and/or download your Vaccine Information Sheet (VIS)
Pneumovax - Please review and/or download your Vaccine Information Sheet (VIS)
Prevnar - Please review and/or download your Vaccine Information Sheet (VIS)
HepA - Please review and/or download your Vaccine Information Sheet (VIS)
HepB - Please review and/or download your Vaccine Information Sheet (VIS)
RSV - Please review and/or download your Vaccine Information Sheet (VIS)
Downtown Pharmacy HIPAA Privacy Notice

Consent:

I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where the patient is not otherwise competent or unable to consent for themselves. I have read, or had explained to me, the Vaccine Information Statement, Vaccine Information Fact Sheet, and/or Patient Fact Sheet about the vaccination(s). I have been given an opportunity to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination(s) as described and I certify the information provided regarding eligibility for the vaccine(s) is accurate. Further, I hereby give my consent to Downtown Pharmacy Inc and the licensed healthcare professional administering the vaccine, as applicable, to administer the vaccine(s) I have requested above to me (or the person named above for whom I am authorized to make this request). I waive and release all claims I, or anyone claiming by or through me, now have or may hereafter acquire against Downtown Pharmacy, and their respective directors, officers, employees, and agents for any damage or injuries if I, or the person named above for whom I am authorized to make this request, contract the disease being vaccinated against, other diseases, or suffer any other adverse reactions following administration of this vaccine. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries. I authorize Downtown Pharmacy (165 William St. NY, NY 10038 / 18 Park View Ave. Jersey City, NJ 07302) to seek reimbursement from my insurance provider for the vaccine(s) I have received and services associated with administration. I have received a copy of the Downtown Pharmacy HIPAA Privacy Notice.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Are you the:

PatientGuardian
Guardian Name
Relation To Patient
Should be Empty:

	Yes	No
Have you had any of the following symptoms in the last 14 Days? (Fever, chills, body ache, fatigue, headache, cough, shortness of breath, difficulty breathing, runny/stuffy nose, loss of smell or taste, sore throat, nausea, vomiting, diarrhea)
Have you tested positive for COVID-19 in the past 14 days?
Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any medication, vaccine, injection, or food?
Have you ever had a reaction after receiving an injection, including fainting or feeling dizzy?
Are you pregnant or considering becoming pregnant?
Do you have a weakened immune system or take medications that weaken your immune system (immunosuppressants, cancer, leukemia, lymphoma, HIV/AIDS, transplant)?
Have you received any other vaccinations or skin tests within the last 4 weeks?
Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?
Do you have a chronic health condition such as cancer, heart disease, HIV/AIDS, diabetes, chronic lung disease, etc.?
Have you ever developed Guillain-Barre Syndrome (a type of paralysis) within 6 weeks of receiving a vaccine?

Vaccine Screening and Consent Form

Pneumonia Vaccine

RSV Vaccine

Patient Information