2025 - General Immunization Consent Form

MEDICAL ARTS PHARMACY IMMUNIZATION CONSENT FORM

(Legal) First Name*

MiddIe Initial

Last Name*

SSN

Date of Birth*

MaleFemale

Phone*

Street Address or PO Box*

Apt No

City*

State*

Zip Code*

Screening Questions for Patient Receiving Vaccine

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).

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

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