Vaccine Consent Form
Appointment
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I WANT TO BE PROTECTED FROM THE FOLLOWING (CHECK ALL THAT APPLY)
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FLU
COVID-19
TDAP
SHINGLES
PNEUMONIA
HEPATITIS A
HEPATITIS B
Other
Name
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First Name
Middle Name
Last Name
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Date of Birth
Sex assigned at birth
Email
example@example.com
Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race:
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Black or African American
American Indian
Hispanic/Latino
White
Asian
Ethnicity
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Not Hispanic/Latino
Hispanic/Latino
Do you have any of the following symptoms today? Fever, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea
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Yes
No
Do you have any allergies to medications, foods (ex: eggs), lates, or a vaccine component (ex: gelatin, neomycin, polymyxin, polyethylene glycol, etc.)
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Yes
No
Other
Have you ever had a serious reaction after receiving a vaccine? (swelling, trouble breathing, seizure, fainting, dizziness)
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Yes
No
Have you had the vaccine (s) you are receiving today before?
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Yes
No
Have you experience seizures, Guillain-Barre Syndrome, or any other neurological disorder?
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Yes
No
Have you received any vaccines in the past 28 days? if yes, please list vaccine(s) and date:
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Yes
No
Other
For Women: Are you currently pregnant, breastfeeding, or are you planning to become pregnant in the next month?
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Yes
No
For Women: Are you currently pregnant, breastfeeding, or are you planning to become pregnant in the next month?
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Yes
No
For Women: Are you currently pregnant, breastfeeding, or are you planning to become pregnant in the next month?
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Yes
No
Do you have cancer, leukemia, lymphoma, HIV/AIDS, organ transplant, or any other immune system problem?
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Yes
No
In the past 3 months, have you taken medications that weaken your immune system, such as anticancer drugs, high dose steroids, chemotherapy, injectable therapy for rheumatoid arthritis, Crohn's disease or psoriasis (ex: Humira) or had radiation treatments?
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Yes
No
I hereby give my consent to the health care provider of
Orchard Village Pharmacy
, its affiliates and subsidiaries, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read and/or had explained to me the CDC's Vaccine Information Statement (VIS). I have had the opportunity to ask questions that were answered to my satisfaction. As with all the medical treatment, there is no guarantee that I will not experience an adverese reaction from the vaccine. I understand that the information contained on this form may be shared with the Michigan Department of Health & Human Services (MDHHS) and/or state immunization registries, and will remain confidential and will not be released except as permitted or required by law. If eligibile, I authorize
Orchard Village Pharmacy
to submit a claim for reimbursment on my behalf to Medicare or any other contracted third party payor. If the calim is denied, I understand that I will be responsible for payment. I acknowledge that I have received a copy of the Notice of Privacy and Practices.
Furthermore, I agree to remain near the vaccination location for approximatley 15-30 minutes after administration for observation by the administering Healthcare provider
Date
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/
Month
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Day
Year
Date
PLEASE PRINT NAME OF LEGAL GUARDIAN & RELATIONSHIP IF PATIENT UNDER AGE 18
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Signature (Parent/Guardian)
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