• Vaccine Informed Consent Form

  • PATIENT INFORMATION

  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Vaccine(s) you would like to receive:*

  • We do not have that vaccine available at this time.

  • Eligibility for the COVID vaccine may vary, please talk with a pharmacy team member for the latest requirements.

  • SCREENING QUESTIONS

  • Do you feel sick today?*
  • Have you received any immunizations in the past 4 weeks?*
  • Do you have an allergy to any food, medication, vaccine, or latex?*
  • Have you ever had a serious reaction or fainted after receiving any vaccination?*
  • Do you carry an EpiPen?*
  • In the past 3 months, have you taken medications that affect immune system such as prednisone, other steroids, or anticancer drugs, drugs for autoimmune disease (RA, Crohn’s, etc.) or had radiation?*
  • Do you have a bleeding disorder or take a blood thinner?*
  • Have you ever had a seizure disorder, brain disorder, or Guillain-Barre Syndrome?*
  • Do you have cancer, leukemia, HIV/AIDS, history of a transplant, or an autoimmune disorder?*
  • Have you received hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving COVID-19 vaccine?*
  • During the past year, have you received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin or an antiviral drug?*
  • Do you have a long-term health problem with heart, lung, kidney, diabetes, asthma, no spleen, cochlear implant, anemia or a blood/bleeding disorder?*
  • Have you had COVID-19 within the last three months?*
  • Do you have a history of myocarditis, pericarditis, or Multisystem Inflammatory Syndrome (MIS-C or MIS-A)?*
  • Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?*
  • FOR WOMEN: Are you pregnant or are you planning on becoming pregnant during the next month?*
  • FOR CHILDREN AGES 2-4: Has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?*
  • FOR CHILDREN/TEENS: Has the child, sibling, or parent had a seizure; has the child had brain or other nervous system problems?*
  • FOR THOSE 50+: Have you had a shingles vaccination or been diagnosed with shingles in last 12 months?*
  • FOR THOSE 65+: Have you ever had a pneumococcal vaccination?*

  • COVID-19 VIS

    Flu Injection VIS

    Flu Mist VIS

    Pneumonia VIS

    Shingles VIS

    RSV VIS

    Other Vaccine Information Statements can be found by clicking here

     

    Notice of Privacy Practices

  • ACKNOWLEDGEMENTS
  • Date
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  • After submitting, you will be redirected to select an appointment time.

    If you are getting multiple vaccines, still select ONE appointment time. We will administer all vaccines at the same time.

  • If you are making appointments for additional people, make sure that a consent form is submitted for EACH person.

  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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