Centralina Bingo Flu Clinic Consent Form

Name*

First NameLast Name

Date of Birth*

Date

Gender*

Race*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please answer the following questions below*

	Yes	No	N/A
Are you feeling sick today
Have you ever had a serious allergic reaction to any vaccine?
Have you received any vaccinations in the past 4 weeks?
Have you taken any steroid medication or antibiotics in the last 14 days
Do you currently take any blood thinning medications?
Do you have any health conditions such as heart disease, diabetes or asthma?
Are you currently pregnant or planning to be pregnant in the next 30 days?

If you answered yes to any questions above please explain below

Are you interested in getting the Updated COVID Booster vaccine with protection against new variants?*

YesNo

Insurance card Image (optional)

if we cannot locate your insurance coverage for any reason someone from the pharmacy will contact you

I hereby give my consent to the administering of the flu vaccine as specified to the choice above. I acknowledge the risks and benefits in administering of the vaccine. I likewise understand that such risks of having side effects or complications associated with the receiving of the vaccine cannot be predicted. I have been advised to stay in the facility for at least 15 minutes after the vaccine has been given to me for observation. I hereby release and hold harmless the facility, its staff, agents, employees, successors, affiliates, subsidiaries, directors, and officers from any and all liabilities or claims whether known or unknown arising from, or in connection with the administration of the vaccine listed above. I authorize the disclosure of my information for the purpose of necessary processing, recording of my information relevant to the administering of the vaccine including claims for costs and fees. I agree to be responsible for any financial cost-sharing amounts, including copays, coinsurance, and other deductibles including those which are not covered by my insurance benefits.

Signature*

VACCINE	LOT NUMBER	EXPIRATION	MANUFACTURER
SPIKEVAX	3043152	05/26/2025	MODERNA
COMIRNATY	lm2215	03/15/2025	PFIZER
FLU >65YR	388492	05/02/2025	FLUAD
FLU QUAD	aw3225b	06/30/2025	FLUCELVAX
RSV	HF7708	02/01/2025	ABRYSVO

IMMUNIZER: RUTVIJ PARIKH, PHARMD

Vaccine Consent Form