Consent For Immunization & Vaccines Form
Select an appointment time
*
Please select the vaccine you are scheduling.
Please Select
Flu vaccine 65 and older (Fluad)
Flu vaccine under 65
COVID Vaccine (Moderna)
Shingle Vaccine (First dose)
Shingle Vaccine (Second dose)
Pneumonia Vaccine (Prevenar 20)
RSV Vaccine
TDAP Vaccine (Adacel)
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Mother's Maiden Name
*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
*
Email
example@example.com
Please Answer All Screening & Immunization Questions
*
Yes
No
1- Are You Sick Today?
2- Do You Have Any Allergies to medications, Food or Vaccines?
3- Have You ever had a serious Reaction OR Fainted After Receiving a vaccination?
4- Do you have a medical condition OR take medication(s) that may weaken your immune system? (e.g. Cancer, Leukemia, HIV, Active shingles, take prednisone, Oral steroids, Anticancer OR Antiviral Drugs)
5-Have you ever received a dose of COVID-19 Vaccine?
6- Are you Pregnant OR are you considering becoming pregnant in the next month?
7- Do you have seizure disorder OR a brain disorder?
8- Have you ever received a PNEUMONIA vaccine?
9- Patients 50 and older OR Immunocompromised?
10 - Have you ever received the SHINGLES Vaccines?
11- Have you received a hepatitis B vaccine series?
12- Have you received the HPV (Human Papillomavirus) Vaccine?
13- Have you received a meningitis vaccine?
Which arm would you like to get the injection on
*
Left Arm
Right Arm
Consent
By signing below, I hereby agree that the information I have given in this form is accurate and complete. I have received all the related statements and opportunity to ask any questions. I voluntarily accept to receive COVID-19 vaccine. I release and discharge all the employees, administrators, agents and governmental bodies from any and all claims.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed
/
Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Vaccine Manufacturer
Flu vaccine 65 and older (Fluad)
Flu vaccine under 65
COVID Vaccine (Moderna)
Shingle Vaccine (First dose)
Shingle Vaccine (Second dose)
Pneumonia Vaccine (Prevenar 20)
RSV Vaccine
TDAP Vaccine (Adacel)
Other
Immunizer Signature
Pharmacy Name
Pharmacy NPI
*
Submit Consent Form (required)
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