Vaccine Consent - Hillcrest

We will be at

Hillcrest Retirement Community

to provide:

2026-27 Flu vaccine

2026-27 COVID-19 vaccine

RSV vaccine

Pneumococcal vaccine

We are not able to bill Kaiser, or some out of state or closed network plans.

The CDC has vaccine recommendations available at https://www.cdc.gov/acip-recs/hcp/vaccine-specific/index.html. Vaccine information and disclosures are also available at www.hendrickspharmacy.com/vaccines.

Vaccine #1. Which vaccine would you like to receive at this appointment?

Vaccine #2. Which additional vaccine would you like at this appointment? (optional)

Vaccine #3. Which additional vaccine would you like at this appointment? (optional)

Sorry, we are currently out of stock of that vaccine selection.

Vaccine Recipient Date of Birth

Select an appointment time (Your selection for an appointment is not set until you complete and submit the entire consent form below.)

Age

A parent or guardian must be present during the vaccine appointment for any patient under age 18.

Rows	Check box
Check this box to indicate that a parent or guardian will be present during the entire vaccine appointment and will sign the consent form.

Sorry, the vaccine you selected has an age restriction.

Please change your selection or correct your birth date.

Sorry, We are currently only providing the Flu vaccine to ages 5 and up.

Please verify the birthdate you have entered.

If the patient is under age 5, you will need to find another provider.

Vaccine Recipient Name

First NameMiddle NameLast Name

Gender at birth

Vaccine Recipient Physical Address

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code

Email (to receive notification of appointment and informational documents)

example@example.com

AGE

Race

Required by California Department of Public Health

Ethnicity

Required by California Department of Public Health

Vaccine Recipient Phone Number

A Cell Phone is preferred to obtain access to the California Digital RecordFormat: (000) 000-0000.

Mother's First Name

Required for proper vaccine documentation

Primary Care Provider Name (optional)

If you would like to have a copy of this record sent to your Primary Care Provider, please provide the name here and inform the staff at check-in.

Emergency Contact Name

Relationship to Emergency Contact

Phone Number of Emergency Contact

Format: (000) 000-0000.

Vaccine Screening Questions (If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional information may be necessary before vaccination.)

Rows	Yes	No
1. Have you ever had a serious reaction after receiving a vaccine?
2. Do you have any of the following: a long-term health problem with heart, lung, kidney, or metabolic disease (e.g. diabetes), asthma, a blood disorder, no spleen, a chochlear implant, or spinal fluid leak? Are you on long-term aspirin therapy?
3. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
4. Do you have a parent, brother, or sister with an immune system problem?
5. Have you had a seizure or a brain or other nervous system problem?
6. Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?
7. In the past year, have you received immune (gamma) globulin, blood/blood products, or an antiviral drug?
8. Are you pregnant, breastfeeding, or planning to become pregnant in the next 3 months?
9. Have you ever felt dizzy or faint before, during, or after a shot?
10. Are you anxious about getting a shot today?

Allergies?

Rows	Yes	No
Do you have allergies to medications, food, a vaccine component, or latex?

Please list any allergies here: blanks

Medications?

Rows	Yes	No
In the past 6 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatment?

Please list any medications that you have taken in the past 6 months which could affect your immune system here: blanks

Previous Vaccinations?

Rows	Yes	No
Have you received any vaccinations in the past 4 weeks?

Which vaccine(s) did you receive in the last 4 weeks? Please list them here: blanks

Consent (check each box below after reading and prior to signing the form)

Rows	Check each box
I understand the benefits and risks of the vaccine as described in the Vaccine Information Statement (VIS) or Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent Form (also available online at http://www.hendrickspharmacy.com/vaccines). I have had a chance to ask questions that were answered to my satisfaction. I am eligible to receive the vaccine at this time according to the current guidelines and 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 Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I acknowledge that my immunization information from this visit will be sent to the California Immunization Registry and may be shared with other providers unless I choose to opt out.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless The Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).
I have read and reviewed the Notice of Privacy Practices provided by the pharmacy (also available online at http://www.HendricksPharmacy.com/NOPP).
I understand that I may be responsible for the cost of the vaccine and its administration should my insurance not cover it.

Insurance (We are not able to bill Kaiser or some out of state or closed network plans)

Rows	Yes	No
Do you have health or medical insurance (examples include Medicare, Medi-Cal, or private health policies)? We are not able to bill Kaiser or some out of state or closed network plans. You are welcome to pay out of pocket for the vaccine if your insurance will not cover the cost.

Type of insurance

Please select the type of prescription insurance that you have. (We can't bill Kaiser or some out of state or closed network plans.)

Sorry, we can't bill Kaiser insurance. If you would like to get a vaccine and pay out of pocket, please change your response. Remove the Kaiser selection and select no insurance.

Sorry, we are only able to bill a vaccine to Medi-Cal for adults age 19 and older. You will need to find a provider enrolled in the Vaccine For Children (VFC) Program.

Insurance ID#

Please enter the ID# from your insurance card (Medicare, Medi-Cal, or Private/Other).

Since you indicated you have insurance, please read and check this box.

Rows	Check box
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you may be responsible for the cost, or a portion of the cost, of the vaccine and its administration should your insurance not fully cover it.

Since you indicated you do not have insurance, please read and check this box.

Rows	Check box
I do not have any insurance or I not not wish to have the pharmacy bill my insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan and I understand that I will have to pay at the pharmacy for the vaccine prior to administration.

Full Name

Date/Time

DoseDate

Date

Hour MinutesAM/PM Option

NextDoseText

Time

Hour Minutes

AM/PM Option

CurrentDate

Date

Vaccine Appointment and Consent - Hillcrest