Vaccine Questionnaire and Consent for Immunization

Vaccine Consent Form

Vaccines available on a walk-in basis Monday-Friday 9am-1pm and 2pm-5pm. This form will be sent directly to the pharmacy after it has been completed. Let us know when you arrive that your paperwork is already complete.
Patient Information

Complete this form to be sent directly to the pharmacy to cut down on time at the pharmacy. *We do not have the egg free flu vaccine*
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Patient Gender*

MaleFemale
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name (if applicable)

First NameLast Name
Email*
example@example.com
Do You Want Insurance to Be Billed?*

Yes, Bill InsuranceNo, I will pay out of Pocket
Patient Last 4 Digits of SSN*
Please enter the last 4 digits of the patient's SSN for insurance look up. Bring card in case needed.
For Travel: Where are you going?
Date Leaving
Which Vaccine would you like to receive? (check all that apply)*

COVID-19 (Spikevax) / 12 years and olderSeasonal Influenza / 6months and olderSeasonal Influenza / 65 years and olderHepatitis A Pediatric (Havrix 720) / 12 months - 18 yearsHepatitis A (Havrix 1440) / 19 years and olderHepatitis A/B (TwinRix) / 18 years and olderHepatitis B (Heplisav) / 18 years and olderHepatitis B 20mcg (Engerix) / 20 years and olderHepatitis B Pediatric 10mcg (Engerix) / Birth - 19 yearsHaemophilus B (HIB) / 2-5 years or immunocompromisedHPV (Gardasil 9) / 9 years - 45 yearsJapanese Encephalitis (Ixiaro) / 3 years and olderMeasles/Mumps/Rubella (MMR) / 12 months and olderMeningitis (Menquadfi) / Birth to 55 yearsMeningitis B (Bexsero) / 10 years - 25 yearsPneumococcal 23 (Pneumovax) / 65 years and olderPneumococcal 13 (Prevnar) / 65 years and olderPneumococcal 23 (Prevnar) / 65 years and olderPolio (IPOL) / 2 months and olderRabies (Rabavert) / All age groupsRSV (Arexvy) / 60 years and olderShingles (Shingrix) / 50 years and olderTetanus/Diptheria (Tenivac) / 7 years and olderTetanus/Diptheria/Ac Pert (Adacel) / 8 years and olderDiptheria/Tetanus/Ac Pert (Infanrix) / 6 weeks - 7 yearsTyphoid (Typhim) / 2 years and olderTyphoid (Vivotif capsules) / 6 years and olderVaricella (Varivax) / 12 months and olderYellow Fever (YF-VAX) / 9 months - 59 years

Vaccine History*

	Yes	No	Not Sure
Are you sick today?
Do you have allergies to medications, food (Eggs) or any vaccine?
Have you ever had a serious reaction after receiving a vaccination?
Do you have cancer, leukemia, AIDS, or any other immune system problem?
do you take cortisone, prednisone, other steroids, antivirals, antibiotics, or anticancer drugs, or are you undergoing any radiation treatments?
In the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin?
Have you received any vaccintations in the past four weeks?
Do you have a neurological disorder that resulted from a vaccine?
Do you want to be signed up for text notifications and reminders?
Do you have any medical conditions?
For Women: Are you pregnant or is there a chance you could become pregnant in the next month?

If you answered "yes" to any of the questions above, please explain here:
I have received the Vaccination Information Sheet (VIS) electroincally, paper availabe upon request, regarding the vaccine(s) marked above. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s) marked above and the notification of my primary care physician. I fully relsease and discharge Hoagland Pharmacy, its affiliates, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.

For Medicare recipients, I hereby authorize the pharmacy to bill Medicare Part B on my behalf. I request that payment of authorized Medicare benefits be made to the pharmacy for teh marked vaccine(s) and administration as furnished to me by the pharmacy. I authroize any holder of medical information about me to release to the Center for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits payable for related services.
Consent For Immunization*

Yes, please vaccinateNo, please i do not want vaccinate
Signature*

Clear
Should be Empty:

Vaccine Consent Form

Patient Information