Lascassas Drugs Influenza Vaccine Consent Form

Influenza/COVID 2024-2025 Vaccine Consent Form
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
FemaleMale
Hispanic or LatinoNon-Hispanic/LatinoUnknownPrefer not to answerOther
African AmericanAmerican IndianAsianCaucasianNative Hawaiian/ Other Pacific IslanderPrefer not to answerOther
Commercial Insurance

BIN NumberPCN NumberGroup NumberID Number
Picture of insurance card

Cancelof
I authorize the pharmacy to bill my insurance on my behalf for the immunization.
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- I certify that the information above is correct and accurate to the best of my knowledge.I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving.All my questions concerning the vaccine have been answered to my satisfaction.I understand the benefits and risks of receiving the vaccine and request that it be given to me.I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.
- Date
  
  MonthDayYear
  Date
- Signature
- Should be Empty:

Influenza/COVID 2024-2025 Vaccine Consent Form