Vaccines for Children Consent Form

IMPORTANT REMINDER: We can only vaccinate children ages 3 and up. If your child is less than 3 years of age, please contact their physician to schedule a vaccination appointment.
Appointment*
Patient Full Name (First MI Last)*
Patient Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Patient Age*
We can only vaccinate children ages 3 and up. If your child is less than 3 years of age, please contact their physician to schedule a vaccination appointment.
For vaccinations for patients 18 years or older, please fill out our adult vaccination consent form: https://form.jotform.com/250906751397061
Phone*
Gender*

FemaleMale
Address*

Address

Street Address Line 2

CityState

Zip Code

Sorry, Due to high demand we do not currently have the following vaccine in stock. All other vaccines are available, please click the back button to continue scheduling those vaccines.

- Covid-19

Thank You!

INSURANCE:
Insurance*

I hereby authorize the pharmacy to bill my insurance on my behalf for vaccine administration fee & receive payment.I do not have insurance
Insurer*
Member*
Rx Group*
BIN*
PCN*
Optional: Upload a photo of your insurance card below

Cancelof

ACKNOWLEDGEMENTS
Privacy Policy

Click here to review Springfield Pharmacy's Privacy Policy

Vaccine Information Statements

COVID-19 VIS | Influenza VIS | DTaP VIS | Hepatits A VIS | Hepatits V VIS | HPV VIS | MMR VIS | Polio VIS | TDaP VIS | Chickenpox VIS | MCV4 VIS

Other Vaccine Information Statements can be found by clicking here
Acknowledgements*

I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Statement (VIS), a copy of which was provided with this Consent and Release. I request the vaccine(s) be given to me or to the person named below, a minor for whom I represent that I am authorized to sign this Consent and Release.I have received a copy of the notice of Privacy Practices and appropriate CDC Vaccine Information Statement (VIS). 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 and 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 of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Name*
Relationship to patient*
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.
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