Ames Vaccine Consent Form 2024

Vaccine Informed Consent Form
PATIENT INFORMATION
Full Name (First MI Last)*
Date of Birth*

MonthDayYear
Date
Age*
Email*
Phone*
Address*

Address

Street Address Line 2

CityState

Zip Code
Primary Care Doctor
Doctor's City and State
Vaccine(s) you would like to receive:*

Flu ShotFlu Mist (2-49 years)COVID-19PneumoniaShinglesRSVTdap (tetanus, diptheria, and pertussis)Other
We do not have that vaccine available at this time.

INSURANCE INFORMATION

I hereby authorize the pharmacy to bill my insurance on my behalf for the vaccine, administration fee, & receive payment.
Insurer
Member
Rx Group
BIN
PCN
Last Four Digits of SSN
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

I attest that the answers provided here are accurate to the best of my knowledge.I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent & Release.I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy & of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature

Clear
Date

MonthDayYear
Date
Parent or Guardian Name
Relationship to patient
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.
Should be Empty:

Vaccine Informed Consent Form

PATIENT INFORMATION

SCREENING QUESTIONS