Infinity Pharmacy COVID Vaccine Consent Form

Vaccine Consent Form
2700 S 60th St, Milwaukee, WI 53219

P: 414-988-0008

F:414-375-6880
*Parents, if your child is under 6 years old, you must have your pediatrician send a prescription BEFORE your appointment.

walk-ins are accepted
For information about the vaccine click on the image
Section I. Personal Information
Patient's Full Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Phone Number:*
Email:
Gender:*

MaleFemale
Race:*

African AmericanAmerican IndianAsianCaucasian / WhiteNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Address:*

Street Address Line 2
What type of vaccine are you scheduling for*

Covid Vaccine +12 Yrs 25-26 Formula (Pfizer, Moderna, Novavax based on availability)
6M-11Y Moderna 25-26 Formula
Flu vaccine 6 month and older
RSV Vaccine
Shingrix Vaccine
Tdap (Tetanus) Vaccine
Hepatitis B (HEPLISAV-B) Vaccine
pneumonia (Prevnar 20) Vaccine
Please Remember that if your child is under 6 years old, you must have your pediatrician send a prescription BEFORE your appointment.
Section III. Appointment Scheduler
Please pick a day and time for your vaccination*
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (Pfizer Fact Sheet) (Pfizer 5-11 Fact Sheet) (J&J fact sheet) (Moderna fact sheet), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

By signing this form, I acknowledge that I/ the person named above are phase eligible according to CDC guidelines.
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of POA/Guardian if Patient is not on their own person)*

Clear
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Acknowledgment of Notice of Privacy Practices:*

Clear
**Please take or upload pictures of front & back of insurance card (both medical and prescription) or state ID for billing purposes*

Browse Files

Cancelof
* For Medicare cardholders, please bring this card with you.
* For all other insurances, please bring your prescription card with you. It should have "RxBIN, RxPCN, RxGRP"
I authorize the pharmacy to bill my insurance on my behalf for the immunization
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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