ShotRx School Form English

ShotRx School Form English
Immunization Consent Form Under 19
Location*
Email*
example@example.com
Name*

STUDENTS FIRST NAMESTUDENTS LAST NAME
MI
AGE*
BIRTH DATE MM/DD/YYYY

MonthDayYear
Date Of Birth
Address*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
Name*

PARENTGUARDIANS FIRST NAMEPARENTGUARDIANS LAST NAME
10-DIGIT PHONE NUMBER*
PARENT/GUARDIANS DATE OF BIRTH*

MonthDayYear
Date
Sex Gender assigned at birth)*

FemaleMale
Race*

American Indian or Alaska NativeAsianBlack or African AmericanWhiteMulti-racialUnknown
Ethnicity*

Hispanic or LatinoNot HispanicUnknown
VACCINES FOR CHILDREN ELIGIBILITY SCREENING

(PLEASE CHECK ONE BELOW)
To determine if a child (0 through 18 years of age) is eligible to receive federal vaccine through the VFC and state programs, at each immunization encounter/visit mark the appropriate eligibility category. If column A-D is marked, the child is eligible for the VFC program. If column E, F, or G is marked the child is not eligible for federal VFC vaccine.
VACCINES FOR CHILDREN ELIGIBILITY SCREENING*

A -Medicaid enrolled (ANY TENNCARE)B -No Health InsuranceC -American Indian or Alaskan NativeD -Underinsured served by FQHC, RHC or deputized providerE -Has health insurance that covers vaccines(NOT TENNCARE)F -**Other underinsuredG -***Enrolled in CHIP (CoverTN)
STUDENTS SOCIAL SECURITY*
INSURANCE COMPANY NAME*
ID*
GROUP#*
NAME*

CARD HOLDERS FIRST NAMECARD HOLDERS LAST NAME
CARD HOLDERS DATE OF BIRTH*

MonthDayYear
Date
Are you sick today?*

YesNo
During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin?*

YesNo
Are you currently being treated for a long-term health problem such as heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder?*

YesNo
Are you currently being treated for Cancer, leukemia, AIDS or any other immune system problem?*

YesNo
Are you currently taking cortisone, prednisone, other steroids or anti-cancer drugs, or have you had X-ray treatments?*

YesNo
For women: Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNo
Do you have a history of Guillain-Barre Syndrome?*

YesNo
Do you have allergies to medications, food or vaccines?*

YesNo
Have you had a seizure, brain or nerve problem?*

YesNo
Are you allergic to latex?*

YesNo
Are you allergic to eggs?*

YesNo
Have you received any vaccinations in the past 4 weeks?*

YesNo
If yes what vaccines
Have you ever had a serious reaction after receiving an immunization?*

YesNo
ADVERSE REACTIONS

A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of any vaccine causing serious harm, or death,is extremely small. Local symptoms may include: slight tenderness, redness, itching or swelling at the site of injection.Systemic symptoms may include: fever, malaise and muscle pain. Other systemic symptoms may occur infrequently. These reactions usually begin 6 to 12 hours after immunization and can persist for a few days. Immediate presumable allergic reactions such as hives, angioedema, allergic asthma or systemic anaphylaxis occur rarely after immunization. These reactions may result from hypersensitive reactions in people with severe egg allergy, and such peopleshould not be given certain vaccines that contain eggs. People with documented immunoglobulin E (IgE)-mediated hypersensitivities to eggs or any othervaccine components, including thimerosal, may also be at increased risk of reactions from immunizations.In the case of a severe reaction such as a high fever, behavior changes or flu-like symptoms that occur after vaccination, see a doctor right away. Signs of anallergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat, or dizziness within a few minutes to afew hours after the shot
I have read the adverse reactions associated with the administration of vaccines. A copy of the vaccine manufacturer’s drug information sheet is available onrequest. Furthermore, I have also had an opportunity to ask questions about these immunizations. I believe the benefits outweigh the risks and I voluntarilyassume full responsibility for any reactions that may result from either my receipt of the immunization(s) or the receipt of the immunization(s) by the personnamed below for whom I am the legal guardian (‘Ward’). My medical record may be shared with my physician or other healthcare provider and the medicalrecord of my Ward may be shared with his/her physician or other healthcare provider. I am requesting that the immunization(s) be given to me or myWard. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release ShotRx, andits affiliates, subsidiaries, divisions, directors, contractors, agents and employees (collectively “Released Parties”), from any and all claims arising out of, inconnection with or in any way related to my receipt and thereceipt by my Ward of this or these immunization(s). Neither ShotRx nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable,responsible or any way accountable for any loss, injury, death or damage suffered or sustained by any person at any time in connection with or as a result ofthis vaccine program or the administration of thevaccines described above. ShotRx will use and disclose your personal and health information or the personal and health information of your Ward, to treat youor your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities weperform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies in regardto you and your Ward’s personal health information. I acknowledge that I have received a copy of the Notice of Privacy Practices.*

Check here to give consent for all required/recommended vaccines and vaccine series as established by state and/or federal guidelinesCheck here if you are only giving consent for one vaccine. Another form must be completed for each vaccine and for each shot in the series
PERMISSIONS*

I give permission to vaccinate my child without a parent or guardian presentA parent or guardian MUST be present to vaccinate my child
Signature/Legal Guardian*

Clear
Print Name*
VACCINE(S)*

DTapHepatitis AHepatitis BHIBHPVMen ACWYMen BMMRPneumococcalPolioDTap-PolioTdapVaricellaInfluenzaCovidDTap-HepB-PolioMMRV
DATE OF VACCINATION DATE VIS GIVEN*

MonthDayYear
Date
CLINIC ADDRESS
ShotRx Health and Wellness Solutions
6084 Apple Tree Dr Suite 11, Memphis, TN 38115
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