VACCINE INFORMED CONSENT FORM
If you are a part of a school, which school do you work at?
*
PATIENT INFORMATION
Full Name (First MI Last)
Date of Birth
/
Month
/
Day
Year
Date
Age
Email
example@example.com
Phone
Format: (000) 000-0000.
Gender
Male
Female
Address
Address
Street Address Line 2
City
State
Postal / Zip Code
Primary Care Doctor
City/State
Which vaccine are you looking to receive?
Seasonal Influenza
Pneumococcal
Shingles
Other
If other, please specify
Do you feel sick today?
Yes
No
Don't know or N/A
Do you have an allergy to any food, medication or vaccine?
Yes
No
Don't know or N/A
If so, please specify allergy. If so, please specify allergy:
Have you ever had a serious reaction or fainted after receiving any vaccination?
Yes
No
Don't know or N/A
Have you ever had a seizure disorder, brain disorder, or Guillain-Barre Syndrome?
Yes
No
Don't know or N/A
For women: Are you pregnant or are you planning on becoming pregnant during the next month?
Yes
No
Don't know or N/A
For children ages 2-4: Has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?
Yes
No
Don't know or N/A
If you are over the age of 65: Have you ever had a pneumococcal vaccination?
Yes
No
Don't know or N/A
For children/teens: Has the child, sibling, or parent had a seizure; has the child had brain or other nervous system problems?
Yes
No
Don't know or N/A
Do you have a long-term health problem with heart, lung, kidney, diabetes, asthma, no spleen, cochlear implant, anemia or a blood/bleeding disorder?
Yes
No
Don't know or N/A
If yes, please specify:
Have you received any immunizations in the past 4 weeks?
Yes
No
Don't know or N/A
If yes, please specify:
Do you have cancer, leukemia, HIV/AIDS, history of a transplant, or an autoimmune disorder?
Yes
No
Don't know or N/A
In the past 3 months, have you taken medications that affect immune system such as prednisone, other steroids, or anticancer drugs, drugs for autoimmune disease (RA, Crohn’s, etc.) or had radiation?
Yes
No
Don't know or N/A
During the past year, have you received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin or an antiviral drug?
Yes
No
Don't know or N/A
INSURANCE INFORMATION
I give consent to Save More Drugs to administer the vaccine and bill my insurance for the administration.
Insurer
Member #
Primary Cardholder Name / Date of Birth
/
Month
/
Day
Year
Date
Rx Group
BIN #
PCN #
If you do not have insurance, please provide your Social Security Number or Driver's License:
ACKNOWLEDGEMENTS
I attest that the answers provided here are accurate to the best of my knowledge.
I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & 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 & Release.
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 & 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 Patient to Receive Vaccine (or Signature of Power of Attorney or Legal Guardian)
Date
/
Month
/
Day
Year
Date
Parent/Guardian Name
Relationship to patient
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