• Vaccine Consent Form

    Complete the form below to schedule your vaccination with Hawthorne Drugs. If you have any questions about the form, please call the pharmacy at 706-548-5227.

  • Patient Information

    Provide your information below. Please note that your contact information will only be used to search your insurance information and send appointment reminders. If we have any questions about your form, someone from the pharmacy will reach out to you directly. If you do not have an email address, please use: deven@hawthornedrugs.com

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Appointment Details

    We offer vaccines at the pharmacy Monday-Friday from 10am to 5pm. You will receive an email reminder the day before your appointment, as well as 2 hours before your appointment.

  • Please select a date and time to receive your vaccine(s):*
  • Which vaccine(s) would you like to receive?*

  • Screening Questions

    The following questions will help us determine if you are eligible for a vaccine. If you answer “yes” to a question, it does not necessarily mean you should not be vaccinated, it just means additional questions must be asked. If a question is not clear, please call the pharmacy at 706-548-5227. 

  • 1. Are you sick today?*
  • 2. Do you have allergies to medications, food, vaccine components or latex?*
  • 3. Have you ever had a serious reaction after receiving a vaccination?*
  • 4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease, anemia or other blood disorder?*
  • 5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
  • 6. In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids' or anticancer drugs; take drugs for the treatment of rheumatoid arthritis, Crohn's disease or psoriasis; or had radiation treatments?*
  • 7. Have you had a seizure or a brain or other nervous system problem (e.g., Guillain-Barre syndrome)?*
  • 8. During the past year, have you received a transfusion of blood or blood products or been given immune (gamma) globulin or an antiviral drug?*
  • 9. For women: Are you pregnant, or is there a chance you could become pregnant during the next month?*
  • 10. Have you received any vaccinations in the past 4 weeks?*
  • Patient Signature*
  •  
  • Should be Empty: