Epipen Consultation

Name*

First NameLast Name

Birth Date*

Date

Patient Gender*

MaleFemale

Are you pregnant and/or breastfeeding?*

YesNo

Race*

Ethnicity*

Mobile Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name (if applicable)

First NameLast Name

Consent for Services

Before providing your consent, be sure that you understand both the pros and cons of receiving treatment from a pharmacy provider. If you have any questions, we will be happy to discuss them with you. Do not sign your name on this form until you have read and understood each statement and the pharmacist has answered any questions that you may have. This information is confidential.

- I understand the benefits and risks of receiving treatment.
- I have voluntarily chosen to receive care service from a pharmacy provider.
- I understand that Pharmacists can assess and treat some authorized conditions, and administer certain services including diagnostic testing, and vaccinations.
- I voluntarily assume full responsibility for any reactions or consequences that may result.
- In the event of side effects, I understand I should call the pharmacy, my doctor, or 911.
- I have had the opportunity to ask any questions I might have about the care and services provided to me by a pharmacy provider and the alternatives prior to my informed consent. I give consent to receive care services from the pharmacy provider, including any medications recommended or prescribed, or instructions from the pharmacy provider.
- I understand if the pharmacy provider cannot provide effective care, I may be referred to an appropriate care provider.

Authorization to Request Treatment

I am requesting participation in receiving treatment for the pharmacist prescribed Motion Sickness program. I certify that the information provided regarding eligibility for the treatment is accurate and request that the treatment be given to me or to the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so.

I authorize the pharmacy providing services to release information to Medicare, Medicaid, or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf to the pharmacy providing services, I certify that the information provided about my Medicare, Medicaid or other coverage is correct.

Disclosure of Records

I understand that the pharmacy providing services may be required to or may voluntarily disclose my health information with respect to this treatment to my healthcare providers, my insurance plan, health systems, hospitals, and/or state or federal registries. I understand that the pharmacy providing services will use and disclose my health information as set forth in the pharmacy privacy policy (a copy is available by request from the pharmacy team).

I have read, and understand the above statements*

Yes

Anaphylaxis Autoinjector Patient Self-Assessment

Before collecting any more health information, we want to emphasize that not all of our patients will be eligible for a prescription for epinephrine, but all patients will still be responsible for paying any applicable consultation fee.

Individuals at least 18 years of age who have a history of anaphylaxis or have allergies that may result in anaphylaxis may be seen through Scripted. Any person who has had previous signs and symptoms of anaphylaxis (emergency) and any person who may need to assist someone at risk for anaphylaxis may also receive medication through Scripted. We recommend you call 911 immediately if you or someone around you is currently having an anaphylactic reaction.

Patient may be eligible if:

- Adults
- Age 18 and older
- Previous signs and symptoms

Patient may not be eligible if:

- Children
- No previous signs or symptoms

If you choose to continue you will be asked to complete a self-assessment with questions that will be reviewed with you by a pharmacist during your consultation at the pharmacy. The pharmacist will refer to your responses to help make a safe, informed decision about appropriate care.

I have read, and understand the above statement*

Yes

Have you had a severe allergic reaction (anaphylaxis) in the past?*

YesNo

Has a doctor prescribed epinephrine to you in the past?*

YesNo

Do you care for a person that has severe allergies and needs to carry an EpiPen?*

YesNo

Do you know the signs and symptoms of a severe allergic reaction (anaphylaxis)?*

YesNo

Are you here to get training on the signs and symptoms of a severe allergic reaction to become certified pursuant per the Emergency Allergy Treatment Act?*

YesNo

Please list any other medications or supplements you take. This includes herbs and over-the-counter products*

Please list any other allergies or drug allergies. *

Type none if no allergies

Is there anything else you would like your pharmacist to know?

Appointment*

By signing below I agree to pay all applicable charges for the EpiPen consultation and any medications that I choose to receive. I understand that if I cancel less than 24 hours prior to the appointment time I will not be refunded.

I have read, and understand the above statements*

My Products*

EpiPen Consultation

$49.00 Quantity

Total

$0.00

Credit Card