WFP Vaccination Scheduler-Parke Wentling exp 07.18.25

  • *IMPORTANT*

    Please come at your scheduled appointment time with your identification and insurance cards.

  • Immunization Consent Form and Appointment Scheduler

    Please complete prior to arriving for your appointment.

  • Vaccination Clinic at Parke Wentling Health Fair and Senior Expo

    Hermitage VFW 5550 E State St, Hermitage, PA 16148 10:00am-1:00pm
  • Date of Birth*
     / /

  •
  • Format: (000) 000-0000.
  • Gender*
  • Which Vaccination(s) were you interested in receiving at your appointment? Check all that apply

  • Patient Consent For Vaccination

  • Patient Date of Birth*
     - -

  • Insurance Information

    By completing this form, you are providing consent for Walberg Family Pharmacies to bill your insurance for the administration of the vaccinations. Please bring all insurance cards at time of appointment.
  • Insurance Information*
  • Image field 134

  • Consent Questions

    Please complete the following questions.
  • 1. Are you sick today?*
  • 2. Do you have allergies to medications, food, eggs, a vaccine component (ex: Neomycin, Formaldehyde, Gentamicin, Polyethylene glycol, thimerosal, gelatin, yeast or latex)?*
  • 3. Have you ever had an severe allergic reaction that required you to use an EpiPen (epinephrine) or required you to go to the hospital?*
  • 4. Have you ever had a serious reaction after a vaccination?
  • 5. Do you have a long term health problem such as heart, lung, kidney, metabolic disease (Diabetes) asthma, anemia or other blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak?
  • 6. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problems? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, herpes, or cold sores?
  • 7. In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids or anticancer drugs, or have you had radiation treatments?
  • 8. Have you had a seizure, brain, or other nervous system problem or Guillian Barre?
  • 9. Have you received any vaccine or TB skin test in the last 4 weeks?*
  • 10. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19 in the past 90 days?*
  • 11. Do you have a bleeding disorder or are you taking a blood thinner?*
  • 12. Are you pregnant or breastfeeding?*
  • 13. Do you have a history of any of the following (check all that apply)

  • Consent for Vaccination

    I have read, or have had read to me, the written information regarding the vaccines being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Walberg Family Pharmacies, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. Parent or guardian must be present at time of vaccination. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I have read and reviewed the Notice of Privacy Practices available at www.walbergfamilypharmacies.com.

  • Pharmacy Use Only

    Do no complete the below questions

  • Right Deltoid / Left Deltoid

    Circle

  • Vaccine Administered:

     

    Product Name/MFG

     

    LOT/EXP

     

    DOSE:

     

    Date Administered:

    DATE OF VIS/EUA, PERSON RECEIVING VIS/DATE RECEIVED

     

  • Signature of Pharmacist Administering 

  • Should be Empty: