Adult Over 19 Vaccine Consent Form

FOR 19 YEARS OF AGE AND OLDER
Location*
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Unsheltered*

Yes, I do NOT have a permanent place to stayNo, I DO have a permanent place to stay
Email Address*
example@example.com
Sex (Gender assigned at birth)*

FemaleMale
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative HawaiianPacific IslanderWhiteMultiracialUnknown
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown
Do you have Medicare? (RED, WHITE, BLUE CARD)*

Yes, I have Medicare Red, White, and Blue CardNo, I DO NOT have Medicare Red, White, Blue Card
Medicare ID Number (Include letters and numbers)*
Medicare RED, WHITE, BLUE CARD*

I will take a picture of my Medicare red, white, and blue cardI will upload a picture of my Medicare red, white, and blue card
Take a picture of your Medicare (RED, WHITE, BLUE CARD)*
Upload a picture of your Medicare (RED, WHITE, BLUE CARD)*

Cancelof
Do you have Medicare Part D?*

Yes, I have Medicare Part DNo, I DO NOT have Medicare Part D
Name of Medicare Part D Insurance*
Medicare Part D ID Number*
Medicare Part D Group Number*
Medicare Part D Card*

I will take a picture of my Medicare Part D cardI will upload a picture of my Medicare Part D card
Take a picture of your Medicare Part D Card*
Upload a picture of your Medicare Part D Card*

Cancelof
Do you have insurance other than Medicare?*

Yes, I have insuranceNo, I do not have any type of insurance
Social Security Number (For Insurance Purposes)*
Social Security Number (For Insurance Purposes)*
Age*
Insurance Company Name*

BlueCare (Tenncare)WellPoint (Tenncare)United Healthcare Community Plan (Tenncare)AmBetterOther Insurance Company Name
ID*
GROUP#*
Insurance Card*

I will take a picture of my insurance cardI will upload a picture of my insurance card
Take a photo of your insurance card*
Upload a photo of your insurance card*

Cancelof
Card Holder's Name*

Card Holder's First NameCard Holder's Last Name
Card Holder's Date of Birth*

MonthDayYear
Date
You will not be charged. Sign to change your PCP for service today only. This is for vaccination billing (BlueCare)*

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You will not be charged. Sign to change your PCP for service today only. This is for vaccination billing (WellPoint)*

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You will not be charged. Sign to change your PCP for service today only. This is for vaccination billing (United Healthcare Community Plan)*

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You will not be charged. Sign to change your PCP for service today only. This is for vaccination billing (United Healthcare Community Plan)*

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Are you 65 or older?*

YesNo
If you are UNDER 65 please select any of the following conditions that you may have*

AsthmaCancerCerebrovascular DiseaseChronic Kidney DiseaseChronic Lung DiseaseChronic Liver DiseaseCystic FibrosisDiabetes Mellitus Type 1Diabetes Mellitus Type 2DementiaDepressionDisabilitiesHeart ConditionsHIVObesityParkinson's DiseasePhysical inactivityPregnant/Recent PregnantPrimary ImmunodeficiencesSmoking, current or formerOrgan TransplantTuberculosisUse of corticosteroids or other immunosuppressive medicationsI DO NOT have any of the above conditions
Which vaccine would you like to receive today?*

Pfizer Covid Vaccine (Comirnaty)Moderna Covid Vaccine (Spikevax)Influenza Vaccine (FLU)Pneumonia VaccineHepatitis A VaccineHepatitis B VaccineHPV VaccineMonkeypox VaccineTDap VaccineShingles (Shingrix)RSV (Arexvy or Abryso)Meningococcal ACWYMeningococcal BMMRVaricellaPolio
VACCINATION SCREENING QUESTIONS (Please check yes or no for each question.)
Are you sick today?*

YesNo
Have you had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine?*

YesNo
Do you carry an Epi-pen for emergency treatment of anaphylaxis?*

YesNo
Are you pregnant or is there a chance you could become pregnant? Are you breastfeeding?*

YesNo
Are you a child or adolescent receiving long-term aspirin therapy?*

YesNo
Have you been diagnosed with Monkeypox virus (MPXV) since May 17, 2022?*

YesNo
Do you have a history of developing keloid scars?*

YesNo
Have you had a Monkeypox (JYNNEOS) vaccine in the last 4 weeks?*

YesNo
When? (Month and Year
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?*

YesNo
Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?*

YesNo
Do you have allergies or reactions to any medications, food, vaccines, or latex?*

YesNo
Please explain
Are you immunocompromised or on a medication that affects your immune system?*

YesNo
Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?*

YesNo
Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving the flu vaccine?*

YesNo
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.
Signature of Patient*

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Date*

MonthDayYear
Date
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FOR 19 YEARS OF AGE AND OLDER

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