NEW Vaccine Informed Consent Form

Vaccine Informed Consent Form
PATIENT INFORMATION
First Name*
Middle Initial*
Last Name*
Date of Birth*

MonthDayYear
Date
Age*
Email*
Phone*
Format: (000) 000-0000.
Address*

Address

Street Address Line 2

CityState

Zip Code
Primary Care Doctor
Doctor's City and State
Flu ShotCOVID-19PneumoniaShinglesRSVTdap (tetanus, diptheria, and pertussis)Other
We do not have that vaccine available at this time.

I hereby authorize the pharmacy to bill my insurance on my behalf for the vaccine, administration fee, & receive payment.
Medicare #
Other Insurance/Secondary
Member ID
Rx BIN #
Rx Group
Rx PCN #
Last Four Digits of SSN
COVID-19 VIS

Flu Injection VIS

Pneumonia VIS

Shingles VIS

RSV VIS

Other Vaccine Information Statements can be found by clicking here

Notice Privacy Practices
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
Date

MonthDayYear
Date
Parent or Guardian Name
Relationship to patient

Select your appointment time
IMPORTANT NOTICE - PLEASE READ CAREFULLY

On this page, you will need click submit twice.

1. Schedule and submit your appointment time, below.

2. Scroll down and click the green submit button at the bottom of this page after submitting your 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.
For confirmation - please enter your selected day and time of your appointment.*

MonthDayYear
Date
Hour MinutesAM/PM Option
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