2025 - General Immunization Consent Form

MEDICAL ARTS PHARMACY IMMUNIZATION CONSENT FORM
(Legal) First Name*
MiddIe Initial
Last Name*
SSN
Date of Birth*
Gender*

MaleFemale
Phone*
Format: (000) 000-0000.
Street Address or PO Box*
Apt No
City*
State*
Zip Code*
Race*

WhiteHispanic/LatinoBlack/African AmericanNative American /Alaska NativeAsianNative HawaiianOther
Vaccinations Needed*

FLUCOVID-19PNEUMONIAT-DAPSHINGRIXHEP-BHEP-AVARIVAXRSVMMR
Screening Questions for Patient Receiving Vaccine
Have you had a COVID-19 vaccine within the last 4 months?*

YesNo
Have you had any other vaccines within the past 4 weeks?*

YesNo
Do you have a fever today? Are you sick today? *

YesNo
Have you ever had severe allergic reaction (anaphylactic reaction) to any vaccine, vaccine component, injectable therapy, food, medication or latex? (Such as difficulty breathing, swelling of your face and throat, fast heartbeat, bad rash all over your body, dizziness and weakness).*

YesNo
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

YesNo
Do you have a history of developing Guillain-Barre Syndrome?*

YesNo
Have you had a seizure or a brain or other nervous system problem?*

YesNo
Do you have cancer or another immune system problem? AND/OR: Are you receiving any immunosuppressive therapy (for example, cortisone, prednisone, or anticancer therapy)? These individuals may still receive vaccines unless otherwise contraindicated.*

YesNo
Do you have a long-term health condition such as heart disease, COPD, asthma, kidney disease, diabetes, anemia, or other blood disorder and/or do you smoke?*

YesNo
For Women: Are you pregnant, breastfeeding or planning to become pregnant? (Women in this category may receive most vaccines; a discussion with your healthcare provider can help make informed decision.)*

YesNo
Release, Assignment, Consent and Waiver:

I consent to the staff to administer the vaccinations listed below to the individual named above. I have reviewed the vaccine information sheet(s) and understand the benefits and risks of receiving the medication(s) and choose to assume this risk. I fully release and discharge the prescribing pharmacist, pharmacy, its affiliations and their officers and employees from any illness, injury, loss or damage that may result from any immunizations administered. Include remaining statement after this. I acknowledge that I have received a copy of the pharmacy's privacy practices according to HIPAA. I consent to the release of medical information when necessary for billing, reimbursement and medical protocol. I also allow for the pharmacy to report any medications received to the state vaccine registry. I am aware that an immunization certified student pharmacist might be administering the vaccination(s).
*** If using Insurance, please complete section below.
Medicaid / ARKids# OR Name of Insurance*
Insurance ID#*
RxBIN#*
RxGROUP# (write "n/a" if there is none)*
RxPCN# (write "n/a" if there is none)*
Signature of Patient / Parent / Guardian*
Date

MonthDayYear
Date
Should be Empty:

*** If using Insurance, please complete section below.