Vaccine Consent Form

Vaccine Consent Form

Wait times may be up to 30 minutes for processing and preparation once you arrive. Thank you!
Appointment*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Date Today

MonthDayYear
Date
Gender
Name of your Primary Care Provider (PCP)

First NameLast Name
PCP Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Vaccine to be Administered*

InfluenzaPrevnar 20ShingrixBoostrix (TDap)COVID-19 (call for availability)RSVOther
Please upload a copy of your insurance card*

Cancelof
Are you feeling sick today?*

YesNo
Do you have any health conditions, such as heart disease, diabetes or asthma?*

YesNo
Please indicate your health conditions below
Do you have allergic reaction to medications, food, or any ingredients or materials used with vaccine (i.e. aluminum, eggs, bovine protein, gelatin, neomycin, gentamicin, latex,polymyxin, thimerosal, preservatives, etc.)?*

YesNo
Please indicate below
Have you ever had a serious reaction after receiving a vaccination, such fainting or feeling dizzy?*

YesNo
Have you ever had a seizures, brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?*

YesNo
Have you received any vaccinations or skin tests in the past 4-8 weeks?*

YesNo
Please list below
Are you currently on home infusions, weekly injections, anticancer drugs or radiation treatments?*

YesNo
Are you currently taking high-dose steroid therapy for longer than 2 weeks?*

YesNo
Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in past year?*

YesNo
Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days?*

YesNo
Are you pregnant or planning to be pregnant in the next 30 days*

YesNo
I hereby give my consent to the administering of the vaccine as specified in the choice above. I acknowledge the risks and benefits in administering of the vaccine. I likewise understand that such risks of having side effects or complications associated with the receiving of the vaccine cannot be predicted.

I have been advised to stay in the facility for at least 15 minutes after the vaccine has been given to me for observation.

I hereby release and hold harmless the facility, its staff, agents, employees, successors, affiliates, subsidiaries, directors, and officers from any and all liabilities or claims whether known or unknown arising from, or in connection with the administration of the vaccine listed above.

I authorize the disclosure of my information for the purpose of necessary processing, recording of my information relevant to the administering of the vaccine including claims for costs and fees.

I agree to be responsible for any financial cost-sharing amounts, including copays, coinsurance, and other deductibles including those which are not covered by my insurance benefits.
Age of Consent*

I hereby declare that I am at least 18 years old and I give my consent with full knowledge and responsibility to the risks and benefits of the vaccine. I have had the opportunity to ask questions and which answers were given to me to my satisfaction.I am the legal representative of the above-named patient. The patient is of legal age and I am executing this document on his/her behalf. He/she have had the opportunity to ask questions and which the answers were provided to him/her to his/her satisfaction.I am the legal guardian of the above-named patient. I am executing this document on his/her behalf with my full consent and authority. I have had the opportunity to ask questions and by which answers were given to me to my satsifaction.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*
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