Ella Pharmacy Adult Vaccine Registration Form

SEP Flu Vaccine Clinic Registration
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Phone Number (no dashes)*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Race*
Required to report to state vaccine registry one of the above
Sex*

FMOther
Name of your primary care provider
Do you have insurance?*

YesNo
Please plan to bring your insurance card or proof of insurance with you to your appointment.
Do you have a Medicare Card (red, white, and blue card)?

YesNo
Enter your Medicare Number (exactly as it appears on your Medicare red, white, and blue card).
Medicare Number (from red, white, and blue card)
Use the following images to help you locate the prescription benefit information on your insurance card so you can complete the form below.

The images of insurance cards are for EXAMPLE ONLY. Your card may look different.

Keep in mind that the information requested in the boxes below may appear on the back side of your card.
Name of Insurance Company
Name associated with pharmacy benefits
Insurance Member ID*
Patient or Member ID (identification number)
RX BIN*
May appear on front or back of your card (must be six digits use leading zeros)
PCN
If your card does not list a PCN, leave this field blank
RX GROUP*
May appear as "RX GRP" on your card

I hereby assign to Ella Community Pharmacy any insurance or third-party benefits available for the vaccine administration fee provided to me. I authorize Ella Community Pharmacy to (a) release my medical information, including details about communicable diseases, mental health, and substance abuse, healthcare professionals, Medicare, Medicaid, or other third-party payers as necessary for care or payment; (b) submit a claim to my insurer for these items and services; and (c) request that authorized benefits be paid to Ella Community Pharmacy. I agree to be fully financially responsible for any copays, coinsurance, deductibles, and costs for services not covered by my insurance. Any payments due are required at the time of service or upon receipt of an invoice if sent by Ella Community Pharmacy.

I agree to allow Ella Community Pharmacy to release information to the Indiana vaccine registry, CHIRP (Children and Hoosier Immunization Registry Program), to record that I have received this vaccine. This information will record the manufacturer and administered dose(s) of the vaccine.

I certify that I am either the patient, at least 18 years old, or the parent/legal guardian of the minor patient, or the legal guardian of the patient. I consent to the administration of the requested vaccine(s) by the healthcare provider or Ella Community Pharmacy. I acknowledge the potential risks and benefits, and confirm that I have received and understood the Vaccine Information Statements. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I agree to remain near the vaccination location for observation for 15 minutes, or 30 minutes if I have a history of anaphylactic reactions. On my behalf, as well as on behalf of my heirs and personal representatives, I release and hold harmless Ella Community Pharmacy, including its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees, from any and all liabilities or claims, whether known or unknown, related to the administration of the vaccine(s).

My signature below confirms that I understand and accept these terms and request the vaccine to be administered.
I hereby declare that all the above given information is accurate, and I consent to receive the vaccine as well as details outlined above.

Clear
Type your name here (to serve as your electronic signature):*
By selecting the "submit" button below, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.
Vaccine Time Slot*
Should be Empty:

	YES	NO	Don't Know
Is the person to be vaccinated sick today?
Does the person to be vaccinated have an allergy to an ingredient of the vaccine?
Has the person to be vaccinated ever had a serious reaction to an influenza vaccine in the past?
Has the person to be vaccinated ever had Guillain-Barré Syndrome?
Has the person to be vaccinated ever felt dizzy or faint before, during, or after a shot?
Is the person to be vaccinated anxious about getting a shot today?

SEP Flu Vaccine Clinic Registration

Screening Checklist for Contraindications to Vaccines for Adults