Springfield Pharmacy Vaccination Consent Form

Full Name First MI Last*
Date of Birth*

MonthDayYear
Date
Age*
Email*
example@example.com
For patients ages 3-17, please use our children's vaccine consent form: https://form.jotform.com/250864432371153

Please note, we do not vaccinate children under the age of 3.
Vaccines to receive*

Flu ShotCOVID-19Pneumonia (age 50+)Shingles (age 50+)RSV (age 60+)TdapOther
Sorry, Due to high demand we do not currently have the following vaccine in stock. All other vaccines are available, to continue scheduling those vaccines please uncheck all the vaccines listed below.

- RSV

Thank You!
Current regulations require anyone under the age of 65 to have an underlying condition to receive the COVID vaccine without a prescription. If you are under 65, please look at this list, if any one of them pretain to you, you qualify to receive the vaccine. We will have you sign a form when you get to the pharmacy. Thank you.

CDC UNDERLYING CONDITIONS:
☐ Asthma
☐ Cancer
☐ Cerebrovascular disease
☐ Chronic kidney disease (People receiving dialysis)
☐ Chronic lung diseases (Bronchiectasis, COPD, Interstitial lung disease, Pulmonary embolism,
Pulmonary hypertension)
☐ Chronic liver diseases (Cirrhosis, Non-alcoholic fatty liver disease, Alcoholic liver disease,
Autoimmune hepatitis)
☐ Cystic fibrosis
☐ Diabetes
☐ Disabilities (Down syndrome)
☐ Heart conditions (heart failure, coronary artery disease, or cardiomyopathies)
☐ HIV
☐ Mental health conditions (Mood disorders, including depression, Schizophrenia disorders)
☐ Neurologic conditions (dementia, Parkinson's Disease)
☐ Obesity
☐ Physical inactivity
☐ Pregnancy and recent pregnancy
☐ Primary immunodeficiencies
☐ Smoking, current and former
☐ Solid organ or blood stem cell transplantation
☐ Tuberculosis
☐ Use of corticosteroids or other immunosuppressive medicines
Appointment*

Patient Phone*
Format: (000) 000-0000.
Patient Gender:*

MaleFemale
Patient Address*

Address

Street Address Line 2

CityState

Zip Code
Primary Care Doctor Name*
Primary Care Doctor City/State*

INSURANCE INFORMATION*

I hereby authorize the pharmacy to bill my insurance on my behalf for vaccine administration fee & receive payment.I do not authorize the pharmacy to bill my insurance
Insurer*
Member Number*
Rx Group*
BIN*
PCN*
Medicare Part B Number
Last 4 digits of your SSN*
Optional: Upload a photo of your insurance card below

Cancelof

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 attest that the answers provided here are accurate to the best of my knowledge.I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. I have had a chance to ask questions that were answered to my satisfaction. 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 & Release.I have received a copy of the notice of Privacy Practices. 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 & 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*
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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Questionnaire