2024 VACCINE CONSENT FORM

2024 VACCINE CONSENT FORM - Winfield Library

Graves Drug will be at the Winfield Public Library on October 18th, 2024 from 1-2pm for a vaccine clinic. We will provide both flu vaccines as well as the new COVID booster.
Clinic Date
Name*

First nameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender *
Address*

Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email
example@example.com
Ethinicity

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answer
Race

Hispanic/LatinoNon-Hispanic/LatinoUnknownPrefer not to answer
Mother's Maiden Name *required by KS Vaccine Registry Program*
Primary Care Physician
Which vaccine(s) would you like to receive today (select all that apply)?*

Flu (under age 65)High Dose Flu (over age 65)COVID 19Other or Unknown
Are you feeling sick today? If filling this form out beforehand, mention to the vaccinator if you are feeling sick on the day of your vaccine.*

YesN0
Have you ever had an allergic reaction or a severe reaction to ANY vaccination or injectable medication or been diagnosed with Guillain-Barre syndrome?*

YesNo
Have you ever had an allergic reaction to latex, or anything else such as food, pets, environment, or medications?*

YesNo
Have you received a vaccine in the past 30 days?*

YesNo
If so, which vaccine?
Do you have a bleeding disorder or are you taking a blood thinner?*

YesNo
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressant drugs or therapies?*

YesNo
Are you pregnant, breastfeeding, or planning to become pregnant in the next 30 days?*

YesNo
Would you like your pharmacist to screen you for other vaccinations you may be eligible for?*

YesNo
Please answer the following questions if you are receiving a COVID 19 vaccine:
Have you received a dose of COVID-19 vaccine?

YesNo
Approximate Date of last COVID vaccine:
Have you had a positive COVID-19 test in the last 6 months?

YesNo
Type of insurance to be billed*

MedicareMedicaidCommercial (through workplace or marketplace)OtherUninsured
State of Issuance
Medicaid Number:
Medicare Number or Social Security Number
Rx BIN
Rx PCN
Rx Group
Cardholder ID number
I have been given a copy and have had explained the information in the "Vaccine Information Statement" regarding the vaccine I am receiving today.

Flu: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf

COVID: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/COVID-19.pdf

All my questions concerning the vaccine have been answered to my satisfaction. I understand the benefits and risks of receiving the vaccine and request that it be given to me. I ask that this vaccine be administered by pharmacist, pharmacy intern, or pharmacy technician. I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.

Patient consent/signature (or parent/guardian)
Signature*

Powered by Jotform SignClear
Date of Consent*

MonthDayYear
Date
Should be Empty:

2024 VACCINE CONSENT FORM - Winfield Library