Multicultural Child and Family Hope Center-Vaccination Clinic

STATUS: [ ] WAIIS [ ] PIONEER REG [ ] E-RX [ ] EHR
Acts Pharmacy & Healthcare Services Immunization Consent Form

Multicultural Child and Family Hope Center

Multicultural Child and Family Hope Center Vaccination Clinic

If there are no available time slots, online registration has closed. You may walk-in during the vaccination clinic and fill out manual forms on-site.
Please select time*
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Patient Height and Weight*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email: (Please make sure this is typed correctly. You will not receive a confirmation email if this is incorrect.) *
example@example.com
FemaleMaleUnspecified
Patient Phone Number*
Format: (000) 000-0000.
Race*
Ethnicity*
Tdap/DTaP (Tetanus, Diphtheria, Pertussis)PolioM-M-RVaricellaHepatitis BHPV (Cancer Preventative)MeningococcalOther: Please specify
Primary Care Provider (PCP) Name

First NameLast Name
List allergies: (e.g. eggs, penicillin, etc.)*
List Health Conditions: (e.g. hypertension, diabetes, hypothyroidism, etc.)*
No insuranceHas Insurance
Please provide us with a copy of you insurance card if applicable
To help us better serve the patient please provide us with a copy of their vaccination record if available
SCREENING QUESTIONS

For Patients: The questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.*

Rows	Yes	No	Don't Know or N/A
1. Are you sick today?
2. Do you have any allergies to medications, food, eggs, yeast, latex or a vaccine component?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines outside of a medical setting?
5. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?
6. Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?
7. In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
8. Have you had a seizure, brain/other nervous system problem or Guillain Barre?
9. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug (including acyclovir, famciclovir, valacyclovir)?
10. Have you received any vaccinations or TB skin test in the past 4 weeks?
11. Do you have a history of fainting, particularly with vaccines?
12. For women: Are you pregnant or is there a chance you could come become pregnant during the next month?
13. For Tdap and adult Td: Do you have a cut, injury, puncture or open would that prompted you to get a tetanus shot?

Consent to Vaccination

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Acts Pharmacy and Healthcare Services, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
Form completed by*

First NameLast Name
SelfParentLegal GuardianOther: Please specify
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)*

Clear
FOR PHARMACY USE ONLY.

Vaccine	Manufacturer	Lot#	Exp date	Sig	Admin site	VIS date	Date VIS given
Fluad65+/Flucelvax	Seqirus Sanofi			Inj 0.5ml IM		08/06/21
Prevnar 20/Prevnar 13 Pneumovax 23	Pfizer Merck			Inj 0.5ml IM		02/04/22 10/30/19
Daptacel (DTap) Boostrix (Tdap)	Sanofi GSK			Inj 0.5ml IM		08/06/21
Engerix B 10mcg/0.5ml Heplisav-B 20mcg/0.5ml Engerix B 20mcg/1ml	GSK Dynavax GSK			Inj 0.5ml IM Inj 0.5ml IM Inj 1ml IM		10/15/21
Havrix	GSK			Inj 0.5ml IM		10/15/21
Gardasil-9 (HPV)	Merck			Inj 0.5ml IM		08/06/21
Ipol (Polio)	Sanofi			Inj 0.5ml IM		08/06/21
Menactra/Menquadfi (Meningococcal)	Sanofi			Inj 0.5ml IM		08/06/21
MMR/Proquad	Merck			Inj 0.5ml SC		08/06/21
Varivax	Merck			Inj 0.5ml SC		08/06/21
Shingrix	GSK			Inj 0.5ml IM		02/04/22
Kinrix/Pediarix	GSK			Inj 0.5ml IM		10/15/21
Vaxelis/Pentacel	Sanofi/Merck			Inj 0.5ml IM		10/15/21
ActHiB	Sanofi			Inj 0.5ml IM		08/06/21
Covid19	Pfizer/Moderna			0.2/0.3/0.5ml IM

Administered by: Signature Date:

[] Jazel Bautista, RPh ___________________ ______________

[] Nga Chuong, PharmD ___________________ ______________

[] _______________________ ___________________ ______________
Should be Empty:

Acts Pharmacy & Healthcare Services Immunization Consent Form

Multicultural Child and Family Hope Center Vaccination Clinic

SCREENING QUESTIONS

Consent to Vaccination