Vaccine Consent Form
9832 Clayton Rd St. Louis MO 63124 | 314-993-4031
Nexus Primary Care
Section A
Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Please select your vaccine(s):
Flu
COVID-19
RSV (prescription needed)
Hepatitis A
Hepatitis B
Pneumonia
Shingles
Tdap
Section B
Please answer the following questions by checking the boxes.
*
Yes
No
Don't Know
Not Applicable
Have you ever received the Tetanus vaccine in the last 10 years?
Are you a current smoker?
Do you have any chronic medical conditions? (such as Asthma, Diabetes, CHF, Immunosupression, or Asplenic)
Age ≥ 60, Have you ever received the Shingles vaccine?
Do you feel sick today?
Do you have allergies to medications, food, latex, or vaccines? (such as Eggs, Thimerosal, Neomycin, Gelatin)
Have you ever had a severe reaction to any vaccination in the past?
For women: Are you pregnant or planning to become pregnant in the next month?
Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain-Barre syndrome, or other nervous system problems?
Have you received any vaccinations in the past 4 weeks?
In the past 3 months, have you taken medications to weaken your immune system? (Such as cortisone, prednisone, other steroids, anticancer drugs, or radiation treatment)
Do you have cancer, leukemia, HIV/AIDs, or any other immune system problem?
During the past year, have you received a transfusion of blood or
blood products, or been given immune (globulin) globulin or an antiviral drug?
Please indicate which arm to inject.
*
Right
Left
Primary Care Physician
*
If you do not wish to provide this information put not applicable or N/A.
Section C
I authorize all Ladue Pharmacy, LLC records to be released and reviewed by an authorized representative of my third party payor or employer as required, to apply for Medicare payment under the Title XVIII of the Social Security Act or other applicable payor plans. I authorize this information to be released and reviewed by any Federal, State or accrediting body or agency as required by the regulatory, licensing or accrediting body. I request that payment of authorized services be made in my behalf. If applicable, I authorize all Ladue records to be released to my employer. I agree to stay in the general area for fifteen (15) minutes after receiving my vaccination to ensure that no immediate reactions occur. I understand that if I experience any side effects, it will by my responsibility to follow up with my physician at my expense. Mild local reactions may include redness, swelling, or tenderness at the site. General reactions may include fever, malaise or muscle pain occurring 6-12 hours after vaccination and can persist for 1-2 days. Severe reactions may include Guillain-Barre Syndrome or anaphylaxis. I hereby certify that the previous history is true and complete to the best of my knowledge. I understand the benefits and risk of the vaccination(s) as described in the Vaccine Information Statement (VIS), a copy of which was provided with this Consent and Release. I release Ladue Pharmacy, LLC, its officers, employees, and agents, from any and all liability that might arise from the vaccine on behalf of my heirs, my personal representatives, and myself. I request the vaccine(s) to be given to me or to the person named below, a minor whom I represent that I am authorized to sign this Consent and Release.
Signature (Parent or Guardian, if minor)
*
Date
*
-
Month
-
Day
Year
Date
This notification is being provided pursuant to 338.010.13, RSMo. I understand and acknowledge the admin. of this vaccine will be entered into the ShowMeVax system administered by the MO Dept. of Health & Sr. Services unless I indicate otherwise below:
Do NOT report my vaccine information to ShowMeVax.
Insurance Card - If you have commercial insurance, please upload your prescription insurance card. (This may be a separate card or the information may be included on your insurance card.) If you are on Medicare, please upload your Medicare Card (red, white, and blue card) and your Part D insurance card.
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