Vaccine Consent Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

primary care physician

PCP phone Number

1. Are you sick today

yesno

2. Do you have allergies to medications, eggs, yeast, a vaccine component, or latex?

yesno

3. Have you ever had a serious reaction after receiving a vaccine?

yesno

4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccine?

yesno

5. Do you have a long-term health problem such as heart disease, lung disease, asthma, liver disease, kidney disease, diabetes, anemia, or other blood disorder?

yesno

6. Do you have cancer, leukemia, HIV/aids, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, herbes, or cold sores?

yesno

7. In the past 3 months, have you taken medications that weakens your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or had radiation treatment?

yesno

8. Have you had a seizer or other nervous system problem or Guillain barre?

yesno

9. During the past year, have you received a transfusion of blood, or been given immune globulin, or antiviral drug ?

yesno

10. For women: Are you pregnant or might become pregnant during the next month?

yesno

11. Have you received any vaccination or tb skin test in the past 4 weeks?

yesno

12. Do you have a history of fainting, particularly with vaccines?

yesno

13. For Tdap and adult Td: Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?

yesno

14. For Zoster: Have you had a reaction to gelatin in the pastor triple antibiotic ointment?

yesno

I have read the adverse reactions associated with the administration of vaccines. The vaccine you are receiving may have been authorized by the FDA under Emergency Use Authorization (EUA).
Vaccines authorized under EUA have been rigorously assessed for efficacy and safety. A copy of the vaccine manufacturer’s drug information sheet is available on request. Furthermore, I have
also had an opportunity to ask questions about these immunizations. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from
either my receipt of the immunization(s) or the receipt of the immunization(s) by the person named below for whom I am the legal guardian (‘Ward’). My medical record may be shared with my
physician or other healthcare provider and the medical record of my Ward may be shared with his/her physician or other healthcare provider. I am requesting that the immunization(s) be given to
me or my Ward. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release Holy Trinity, and its affiliates, subsidiaries,
divisions, directors, contractors, agents and employees (collectively “Released Parties”), from any and all claims arising out of, in connection with or in any way related to my receipt and the
receipt by my Ward of this or these immunization(s). Neither Costco nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable, responsible or any way accountable
for any loss, injury, death or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described
above. Holy Trinity will use and disclose your personal and health information or the personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we
provide, and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY
PRACTICES to help you better understand our policies in regard to you and your Ward’s personal health information. I acknowledge that I have received a copy of the Notice of Privacy Practices.

Signature

date

Vaccine Consent Form

Screening Questions

Consent