Vaccine Consent Form

Vaccine Consent Form

Jones Drug Store 101 W. Main St. Jones, OK 73049 (405) 399-2277
**Important Information**

If you prefer a specific vaccine type please call ahead to ensure that we have your preferred vaccine before your appointment.
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Social Security Number*
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age*
County of Residence
Mother's Maiden Name
Race

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhitePrefer not to answer
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoUnknown
Payment Method*

Insurance BenefitCashCheckCredit Card
Insurance Policy

Health ChoiceBlue Cross Blue ShieldCommunity CareGlobal HealthOther
Name as it appears on the insurance card if different
Patient's relationship to the insured

SelfSpouseChild
Member's ID
Member's Group #
BIN
PCN
Check Number
Credit Card Number
Exp Date (Ex. MM/YY)
CVV
Home Pharmacy
Primary Care Physician
Primary Care City
Primary Care Phone Number
Please enter a valid phone number.
Are you Medicare Part B eligible?

YesNo
If yes, provide number and letter on Medicare Red/White/Blue card
Vaccine you would like to receive today:*

Flu VaccinePrevnar 20(pneumococcal)Tdap (Tetanus/Diptheria/Pertussis)Pneumovax 23(pneumococcal)Shingrix (Shingles)Hepatitis AHepatitis BCV19 Comirnaty (Pfizer)SpikeVax (Moderna)RSVGardasil (HPV)Other
Any other vaccines you would like to receive that was not listed? (Separate by commas)

PLEASE INDICATE YES OR NO FOR THE PERSON RECEIVING VACCINE TODAY*

	Yes	No
1. Are you feeling ill today?
2. Do you have allergies to medications, food, latex, or any vaccine?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have any current or ongoing health problems such as heart, lung, thymus, kidney disease, metabolic disease (i.e. diabetes) or blood disorders?
5. In the past 3 months, have you taken cortisone, prednisone, other steroids, or anticancer drugs or have you had radiation treatment?
6. Have you ever had a seizure or a brain or other nervous system problem?
7. During the past year, have you received a transfusion of blood or blood product or been given immune (gamma) globulin or an antiviral drug?
8. Women: Are you pregnant, trying to become pregnant during the next month, or breastfeeding?
9. Have you received any other vaccinations in the past 4 weeks?
10. Do you currently reside with anyone who is immunocompromised? (Such as cancer, leukemia, AIDS, etc.)
11. Do you have a fever or above-normal temperature (greater than 100.4 F)?
12. Are you experiencing shortness of breath , a dry cough, or having troubles breathing?
13. Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
14. Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?

Authorization Assignment of benefit and information release I certify that the information I furnish is true and correct. I know it is a crime to fill out this form with facts that I know are false or to leave out facts that are important. I hereby authorize Jones Drug Store to submit a claim to my insurance carrier or its intermediaries for all covered prescriptions or durable medical equipment and authorize and direct my insurance carrier or its intermediaries to issue payment directly to Jones Drug Store. I hereby authorize Jones Drug Store to furnish complete information requested by my insurance carrier or its intermediaries regarding services rendered. I further agree that I am responsible for paying my co-pays or balances which remain after insurance payments have been made, including any cost of collection or legal fee incurred to collect these balances. Assignment of benefit I request that payment of authorized Medicare benefits be made to me or on my behalf Jones Drug Store for prescription medications or durable medical equipment and supplies ordered by my physician. I authorize any holder of medical information about me to release to the Center for Medicare Medicaid Services and it’s agency any information needed to determine these benefits or the benefits payable for related services. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If ‘other insurance’ is indicated in item 9 of the HCFA-1500 claim form, or elsewhere on the approved claim form or electronically submitted claims, my signature authorizes releasing the information to the insurer or agency listed. In Medicare assigned cases, the supplier agrees to accept the charge of determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered items. Coinsurance and the deductible are based upon the charge determination to the Medicare carrier.
I have read, or have had explained to me, information about the disease and vaccine listed below. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine cited and ask the vaccine be given to me or to the person named above (for whom I am authorized to make this request). I understand that it is recommended that I (or patient listed above) stay on location for 15 minutes following the injection.
Signature*

Clear
Date*

MonthDayYear
Date
I have read or had explained to me the information contained in the Emergency Use Authorization Fact Sheet for Recipients and Caregivers for the vaccinations and understand the risks and benefits of the vaccine(s). I have had a chance to ask questions which have been answered to my satisfaction I understand the benefits and risks of the vaccine. I understand that if my dependent exhibits disruptive behavior while staff is trying to administer the vaccine, they will not receive the vaccine at this clinic and will have to be taken Jones Drug Store or to their provider for this vaccine. I authorize disclosure of this vaccination information to public health officials and other health care professionals. I understand that this vaccination will be recorded in the Oklahoma State Immunization Information System (OSIIS) for the purposes of sharing vaccination information with other health care providers and tracking vaccine inventory only. “In the event of an emergency situation, emergency medication (Epinephrine/Benadryl) and/or oxygen may be administered to my child or adult conservatee. In the event of an emergency situation where I am not present, I authorize Jones Drug Store or designee to obtain any necessary medical care they deem necessary including, but not limited to, obtaining paramedic assistance and transport to a local hospital for additional treatment or observation.”
Signature of Parent or Guardian

Clear
Date

MonthDayYear
Date
Please Print Parent or Guardian Name
Should be Empty:

Vaccine Consent Form

**Important Information**

Important Information