VACCINATION CONSENT FORM

Name

First nameLast Name

Date of birth

Date

Address

Street Address Line 2

City/State/ZIP

Gender

MaleFemaleOther

Primary Care Physician

If we are coming to your location or facility please state the name of you facility and the date we are coming.

Type of Vaccination

If Covid Vaccine please type the date(s) of previous vaccine(s)

Insurance/Payment Type: Medicare, Private (name of ins), or Cash

Bin

ID

Group

Please Answer the following questions.

1. Are you sick today?

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

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

4. Have you ever been diagnosed with Gillian-Barre Syndrome?

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

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

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

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

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

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

If you answered yes to any of the folowing, please explain in the box below with the corresponding number of the question.

- I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, Thereby give my consent to Valley Pharmacy & DME of East Alabama, Inc. to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and I have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering healthcare provider. On behalf of myself, my heirs and personal representatives, Thereby release and hold harmless Valley Pharmacy & DME of East Alabama, Inc., its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. If this claim is to be billed to insurance, I request that payment of Medicare, Medicaid, or other insurance benefits be made on my behalf to Valley Pharmacy & DME of East Alabama, Inc. for any medical supplies and/or medications furnished to me by Valley Pharmacy & DME of East Alabama, Inc. I authorize any holder of medical information about me to release to Valley Pharmacy & DME of East Alabama, Inc., my physician(s), caregiver, CMS, its agents and to my primary and/or other medical insurer any information needed to determine or secure eligibility information and/or reimbursement for covered services. I agree to pay all amounts that are not covered by my insurer(s) including applicable co-pays and/or deductibles for which I am responsible.

Patient Signature

Date