Adult Over 19 Vaccine Consent Form

  • FOR 19 YEARS OF AGE AND OLDER

  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Unsheltered*
  • Sex (Gender assigned at birth)*
  • Race*
  • Ethnicity*
  • Do you have Medicare? (RED, WHITE, BLUE CARD)*
  • Medicare RED, WHITE, BLUE CARD*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you have Medicare Part D?*
  • Medicare Part D Card*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you have insurance other than Medicare?*
  • Insurance Company Name*
  • Insurance Card*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Card Holder's Date of Birth*
     - -
  • Are you 65 or older?*
  • If you are UNDER 65 please select any of the following conditions that you may have*
  • Which vaccine would you like to receive today?*

  • VACCINATION SCREENING QUESTIONS (Please check yes or no for each question.)

  • Are you sick today?*
  • Have you had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine?*
  • Do you carry an Epi-pen for emergency treatment of anaphylaxis?*
  • Are you pregnant or is there a chance you could become pregnant? Are you breastfeeding?*
  • Are you a child or adolescent receiving long-term aspirin therapy?*
  • Have you been diagnosed with Monkeypox virus (MPXV) since May 17, 2022?*
  • Do you have a history of developing keloid scars?*
  • Have you had a Monkeypox (JYNNEOS) vaccine in the last 4 weeks?*
  • Have you had in the last 10 days fever, chills, cough, shortness of breath, difficulty breating, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea?*
  • Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?*
  • Do you have allergies or reactions to any medications, food, vaccines, or latex?*
  • Are you immunocompromised or on a medication that affects your immune system?*
  • Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?*
  • Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving the flu vaccine?*

  •  

     

    I certify that I am:(a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to ShotRx or its agents to administer the vaccine(s) I have chosen today.

  • I certify that I am:(a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to ShotRx or its agents to administer the vaccine(s) I have chosen today.

    I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s I understand the risks and benefits associated with the vaccine(s) and have received, read and/or had explained to me the VIS (Vaccine Information Sheet) or the Emergency Authorization Fact Sheet on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.

    I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.

    On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the ShotRx, and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.

    I acknowledge that: (a) I understand the purposes/benefits of TENNIIS, Tennessee's immunization registry and (b) DOH will include my personal immunization information in TENNIIS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.

    I further authorize ShotRx or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to ShotRx or its agents with respect to the above requested items and services. I understand that NO payment is due from me individually at this time for vaccination services. However, if my claim is denied, I understand that I will be responsible for payment.

    I acknowledge receipt of the Notice of Privacy Rights.

  • Date*
     / /
  • Should be Empty: