TWAIN HARTE PHARMACY VACCINE CONSENT

Clinic Date (more will be added based on availability and need)

Oct 12, 2025Nov 2, 2025I am a Big Trees MD Member and would like to schedule a private vaccination appointment.

Vaccine Type You Are Receiving:*

First Name*

MI*

Last Name*

Address*

Address

Street Address Line 2

CityState

Zip

Phone Number*

Please enter a valid phone number.

PHYSICIAN*

Date of Birth MMDDYYYY*

Date

Age*

Is your age 65+ years or older*

YesNo

Gender*

Parent or Legal Guardian (if applicable)

First Name

Last Name

Relationship to the patient

Phone

Are you feeling sick today? If yes, please do not attend the clinic and reschedule.*

Have you ever had a flu vaccine?*

Have you ever had a serious reaction to any vaccine in the past?*

Do you have an allergy to a component of the vaccine (MSG, gentamicin, gelatin)?*

Have you ever been diagnosed with Gullain-Barre Syndrome?*

Are you pregnant or possibly pregnant?*

What type of insurance(s) do you have?

RxBIN*

RxPCN*

RxGroup*

Member ID*

FRONT OF INSURANCE CARD(s)*

BACK OF INSURANCE CARD(s)*

Consent to Administer Vaccination & Enter Information Into Immunization Registry

To the best of my knowledge, I understand the benefits and/or risks of the vaccine I am receiving today. I hereby give consent to Twain Harte Pharmacy (THP) staff for the administration of the vaccine to myself or for the individual for whom I am authorized to make said request. I have received a copy of the most up-to-date Vaccine Information Statement (VIS I understand that I will have the chance to ask questions and have them answered to my satisfaction. As with all medical treatment, there is no guarantee that I will not experience an adverse reaction from the vaccine. I fully release and hold harmless Twain Harte Pharmacy, its officers, directors, and employees from all liabilities or claims arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. THP is authorized to enter my vaccination information into the statewide immunization database. This information could be shared with my healthcare provider as part of my medical record. I FULLY UNDERSTAND THAT I WILL BE ULTIMATELY RESPONSIBLE FOR ANY CHARGES if I am not a covered person under the insurance plan (program listed above), the services are not covered services, or any co-pays, deductibles or coinsurance obligations apply. Furthermore, I agree to remain near the vaccination location for approximately15-20 minutes after administration for observation by the administering healthcare provider.

COVID-19 BOOSTER INFORMATION

A booster dose of the COVID-19 Moderna or Pfizer vaccine is recommended if you: Received your second vaccine dose at least 6 months ago, AND Are age 65 or older, or Are age 18 or older who live in long-term care settings, or Are age 18 or older who have underlying medical conditions, or Are age 18 or older who are at increased risk due to social inequity, or Are age 18 or older who work or live in high-risk settings

A booster dose of the COVID-19 Janssen (Johnson and Johnson) vaccine is recommended if you received your first dose of the Janssen vaccine at least 2 months ago, and Are age 18 or older Individuals eligible for a booster may receive either the same or a different COVID-19 vaccine as a booster dose, depending on advice from a health care provider, individual preference, availability, or convenience.

**Examples of underlying medical conditions may include, but are not limited to the following: Cancer, Cerebrovascular disease or Stroke, Chronic Kidney Disease, Chronic Lung Diseases (including COPD), Asthma, Interstitial Lung Disease, Cystic Fibrosis, or Pulmonary Hypertension), Dementia or other Neurological Conditions, Diabetes, Down Syndrome, Heart Conditions (such as Heart Failure, Coronary Artery Disease, or Cardiomyopathies), HIV/AIDS, Immunocompromised State (weakened immune system), Liver Disease, Overweight or Obesity (BMI >30), Pregnancy and Recent Pregnancy, Sickle Cell Disease or Thalassemia, Smoking (current or former), Solid Organ or Blood Stem Cell Transplant, Substance Use Disorder **Example of occupations at increased risk for Covid-19 exposure and transmission may include, but are not limited to the following: First responders (healthcare workers, firefighters, police, congregate care staff), Education staff (teachers, support staff, daycare workers), Food and agriculture workers, Corrections workers, USPS workers, Public transit workers, Grocery store workers

By signing below, I confirm that I meet the requirements above and am eligible for a COVID-19 booster dose.

I acknowledge that I have read the above VIS and I have been able to get any questions I have prior to vaccination answered to my satisfaction.*

I acknowledge I have reviewed the above VIS for the vaccination I am receiving today.

TYPE OR COPY AND PASTE THE FOLLOWING STATEMENT INTO THE BOX BELOW: Yes, I AM UNDER 65 YEARS OF AGE AND I HAVE AN UNDERLYING HEALTH CONDITION (The State of CA requires us to ask this so it needs to be completed if you are under 65 and are looking for a free vaccine).

Signature

Print Name

Relationship to Client

Date

Twain Harte Pharmacy Vaccine Form for Big Trees MD Vaccination Clinic

SCREENING HEALTH QUESTIONS FOR PERSON RECEIVING VACCINE

INSURANCE INFORMATION

INSURANCE INFORMATION CARD

VACCINE INFORMATION SHEETS (VIS)

COVID-19

INFLUENZA

PNEUMONIA

SHINGLES

TDAP

RSV