HORSHAM SQUARE PHARMACY VACCINE CONSENT FORM

Section I: Information about patient to recieve vaccine

Please Complete the following information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

FemaleMale
Cell Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please select what vaccine(s) you would like to receive. (Max is 2 vaccines at once)

RSV -Respiratory Syncytial Virus (Arexvy, Abrysvo)COVID-19 vaccine- COV-MOD (SPIKEVAX)Hepatitis A and Hepatitis B vaccine (HepA-HepB Twinrix®)Hepatitis B vaccine (HepB Engerix-B®, HEPLISAV-B, PREHEVRIO, RECOMBIVAX HB)Influenza vaccine (inactivated)- FLU (Fluarix, Flulaval, Fluzone, Afluria, Fluad, Flucelvax)Pneumococcal conjugate vaccine- (PCV20 Prevnar 20™)Pneumococcal polysaccharide vaccine- (PPSV23 Pneumovax 23®)Tetanus & diphtheria toxoids & acellular pertussis-(Tdap ADACEL OR BOOSTRIX)Zoster vaccine, recombinant-RZV (Shingrix)
Section 2 : Insurance Information

Please bring your Insurance Card and ID when you come in for your vaccines
Please complete the information on your Pharmacy Insurance Card
Rx Bin:
Rx Pcn:
Rx ID:
Rx Group:
Please provide information on your Medical Insurance Card
Insurance Carrier
Id Number:
Group Number:
Help Desk Phone number
Please enter a valid phone number.
Medicare Number (from red & blue card) (IF Applicable) or enter your Social Security number below and we will locate your Medicare number for you.
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security CardState identification number and state of issuanceDriver's license number and state of issuance
Section 3: Please answer the following screening questions
Please select your race
Are you Hispanic or Latino?

YesNoDon't Know
1. Are you feeling sick today or have you been sick in the last 2 weeks?

YesNoDon't Know
2. Do you have allergies to medications, food, a vaccine ingredient, or latex?*

YesNoDon't Know
3. Have you ever had a serious reaction after receiving a vaccine?*

YesNoDon't Know
4. Do you have a long-term health problem with heart, lung, kidney, or metabolic disease, asthma, a blood clotting disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on a long-term aspirin therapy?*

YesNoDon't Know
5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*

YesNoDon't Know
6. Do you have a parent, brother, or sister with an immune system problem?*

YesNoDon't Know
7. In the past 3 months, have you taken medicines that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?*

YesNoDon't Know
8. Have you had a seizure, brain or other nervous system problem?*

YesNoDon't Know
9. During the past year, have you received a transfusion of blood or blood products?*

YesNoDon't Know
10. Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNoDon't Know
11. Have you received any vaccinations in the past 2 weeks?*

YesNoDon't Know
12. Have you have received all the following vaccines: Pneumococcal, Shingles, and Tdap?*

YesNoDon't Know
Parent/Legal Guardian (If patient is 18 years of age or younger)
Parent/ Legal Guardian Name
Parent/ Legal Guardian Phone Number
Relationship
Address

Street Address

Street Address Line 2

CityState

Zip Code
Section 4: Please read the following and sign below
Consent for services: I have been provided with the Vaccine Information Sheets or patient fact sheet corresponding to the vaccine that I am receiving. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make the request. All VIS forms are available in the pharmacy and you may access all forms with your cell phone as well.
Authorization to request payment: I do hereby authorize Horsham Square Pharmacy to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or my prescription insurance. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.
Disclosure of records: I understand that Horsham Square Pharmacy may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at Horsham Square Pharmacy, my Primacy Care Physician, my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or understand that Horsham Square Pharmacy will use and disclose my health information asset forth in their Notice of Privacy Practices (copy available in store).

Dr. James Mahoney has authorizations for all vaccines given by Horsham Square Pharmacy. The master copy is located in the pharmacy.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Name & Title of Vaccine Administrator:__________________________________

Date of Administration: _____________________________________________

Route of Administration: L or R arm IM other______________
Should be Empty:

Section I: Information about patient to recieve vaccine

Section 2 : Insurance Information

Section 3: Please answer the following screening questions

Section 4: Please read the following and sign below