Immunization Consent - updated 2023

Full Name of Person Receiving Vaccine*

For children under 18, name of parent/guardian completing this form:

Date of Birth*

Date

Gender*

Race*

Ethnicity*

Address*

Address

Street Address Line 2

CityState

Zip

Phone*

Format: (000) 000-0000.

Allergies

Primary Care Physician

Office Phone Number (if available)

Format: (000) 000-0000.

Do you have insurance?*

Insurance BIN Number:

Insurance PCN Number:

Insurance Group Number:

Insurance ID Number:

Which immunization(s) are you receiving today?*

Are you sick today?*

YesNo

Do you have allergies to medications, food, yeast, a vaccine component, PEG, polysorbate, or latex? (If yes, list in allergy field above)*

YesNo

Have you ever had a serious reaction after receiving a vaccination?*

YesNo

Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*

YesNo

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

YesNo

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Or have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn?s disease, herpes, or cold sores?*

YesNo

In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*

YesNo

Have you had a seizure or a brain or other nervous system problem or Guillain Barre?*

YesNo

During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug (including acyclovir famciclovir, valacyclovir)?*

YesNo

Do you have a history of fainting, particularly with vaccines?*

YesNo

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

YesNo

For Tdap and adult Td: Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?

YesNo

For Zoster (shingles): Have you had a past reaction to gelatin, neomycin or triple antibiotic ointment?

YesNo

Will you be receiving your vaccine from Hale Center Clinical Pharmacy on-site at your school or workplace? If so, please list your school or workplace:

Consent: I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answeredto mysatisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, andhold harmless Hale Center Clinical Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby givemyconsent tothepharmacists of Hale Center Clinical Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Signature (Parent/Guardian must sign for children under 18.) *

Date*

Date

Email*

example@example.com

Optional: Would you like to make an appointment for your vaccine at Hale Center Clinical Pharmacy? If so, please schedule here. (Note: walk-ins are always welcome. Do not schedule if your flu shot is at a school or work-site clinic.)

YesNo

Type a question