• Immunization Consent Form

    Immunization Consent Form

    Please have your pharmacy insurance card ready when completing.
  • Appointment*
  • Please enter the date & time selected for your appointment.*
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  • Section A

    Individual & Contact Information
  • Date of Birth*
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  • Birth sex*
  • Format: (000) 000-0000.

  • Payment

    Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
  • Choose a payment method*

  • Insurance Card Information

    Please input each of the following from your commercial / Medicare Part D insurance card.

  • Section B

    The following information will help us determine your eligibility to be vaccinated.
  • 1. Which vaccines are you requesting to have administered? Please check all requested vaccines.
  • 2. Do you feel sick today?
  • 3. Do you have allergies to medications, foods, or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymixin, neomycin, phenol, or thimerosal)
  • 4. Have you ever had a serious reaction to a vaccine in the past?
  • 5. Have you ever had: (please mark all that you HAVE experienced)
  • 6. Are you 65 years of age and older?
  • 7. Do you smoke or have a chronic condition or long-term health problem?
  • If yes, please check all that apply:
  • If you answered Yes to question #6 or 7, have you ever had a pneumonia vaccination?
  • Have you ever had a shingles vaccination (for patients 50 years of age and older only)?
  • Are you a healthcare worker?
  • For women: Are you pregnant or considering becoming pregnant in the next month?

  • Section C

  • I certify that I am: (I) the patient and at least 18 years of age; (II) the parent or legal guardian of the minor patient; or (III) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statement on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering healthcare provider. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Brehme Drug, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that: I understand the purposes/benefits of my state's immunization registry ("State Registry" I acknowledge that, depending on my state law, I may prevent, by using a state-approved opt-out form ("Opt-Out Form") (a) disclosure of my immunization information to the State Registry; or (b) the State Registry from sharing my immunization information with any of my other healthcare providers enrolled in the State Registry. Brehme Drug will, if my state permits, provide me with an Opt-Out Form. Unless I provide Brehme Drug with a signed Opt-Out Form, I elect to participate fully in, and consent to Brehme Drug reporting my immunization information to the State Registry. I authorize Brehme Drug to (1) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf to Brehme Drug with respect to the above requested items and services. I further agree to be fully financially responsible for any cosharing amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, if Brehme Drug invoices me after the time of service, upon receipt of such invoice.

  • Date
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  • Should be Empty: