Vaccination Consent Form

Vaccination Consent Form

Whitaker Pharmacy. 570 Indian Mound Dr. Mount Sterling, KY 40353. 859-498-3141
Date

MonthDayYear
Date
Which vaccine are you requesting today? (check all that apply)

FluRSVPneumoniaMeningitisCOVID 19ShinglesOther
Your Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Primary Doctor

First NameLast Name
Have you had a physical exam by a doctor in the last year?

YesNo
Do you have a fever or feel sick today?

YesNo
Do you have any allergies to medications, foods (ie eggs), latex, or a vaccine component (gelatin, neomycin, polymyxin, yeast, thimerosal, etc)?

YesNo
If yes, please explain allergy here:
Have you ever had a serious reaction after receiving a vaccine? (swelling, trouble breathing, seizure, etc.)

YesNo
Have you had the vaccine(s) you are receiving today before?

YesNo
Have you experienced seizures, Guillain-Barré syndrome, or any other persistent neurological disorder?

YesNo
Have you received any other vaccines in the last 28 days?

YesNo
FOR WOMEN: Are you currently pregnant, breast feeding, or planning to become pregnant in the next month?

YesNo
If under 18, name of parent or legal guardian

First NameLast Name
Please provide a picture of the FRONT of your Prescription Insurance Card or Medicare B Card if applicable:
Please provide a copy of the BACK of your Prescription Insurance Card
I give my consent to the healthcare provider of Whitaker Pharmacy, its affiliates and subsidiaries, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read, and/or had explained to me the CDC's Vaccine Information Statement (VIS) for the vaccine(s) I have elected to receive. I have had the opportunity to ask questions that were answered to satisfaction. I understand that the information contained on this form may be shared with state immunization registries, and will remain confidential and not released except as permitted or required by law. I agree to remain near the vaccination area for approximately 15-20 minutes after administration for observation by the healthcare provider.
Signature of patient/parent or legal guardian:

Clear
Date Signed

MonthDayYear
Date
Should be Empty: