Wright Flu Consent Form

VACCINE INFORMED CONSENT FORM
PATIENT INFORMATION
Full Name (First MI Last)*
Date of Birth*

MonthDayYear
Age*
Gender

MaleFemale
Email
Phone*
Address*

Address

Street Address Line 2

CityState

Zip Code
Primary Care Doctor
City/State

INSURANCE INFORMATION

I hereby authorize the pharmacy to bill my Insurance on my behalf for the immunizations and receive payment.Please mark here if you do not have insurance and provide your social security number or driver's license number.
Insurer
Member #
Rx Group
BIN #
PCN #
Social Security Number
Driver’s License
Flu Injection VIS

Flu Mist VIS

Other Vaccine Information Statements can be found by clicking here

Notice of Privacy Practices
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)

Clear
Date

MonthDayYear
Date
Parent/Guardian Name
Relationship to patient
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.
Should be Empty:

VACCINE INFORMED CONSENT FORM

PATIENT INFORMATION

SCREENING QUESTIONS