Edencrest Adel Clinic Immunization Consent Form

Vaccine(s) to receive?

FLU Vaccine 2025-2026 Age 3-64FLU Vaccine 2025-2026 Age 65 and over

Patient Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth*

MonthDayYear

Age

Cell Phone Number*

Email

example@example.com

Gender*

FemaleMale

Social Security Number*

Choose a payment method*

BIN number

PCN

Rx Group

ID Number

Medicare Number (if applicable - from Red/White/Blue Medicare Card

Primary Care Provider (PCP) Name

First NameLast Name

I will attend the HALLOWEEN SPOOKY SHOT AND SHOP EVENT on October 29, 2021. Get your vaccine and take advantage of 20% off most OTC purchases. An extra 5% off for anyone in costume!

YesNo, I prefer to come a different day

Please tell us the most likely day you will be in for your vaccine. This is NOT an appointment. Vaccines are still done on a walk-in basis, however this information simply helps us plan how to serve you better. No need to contact us if you come a different day.

Date

Are you sick today?*

YesNo

Do you have any allergies to medications, food, yeast, latex, or a vaccine component?*

NoYes, please list:

Have you ever had a serious reaction after receiving a vaccination?*

YesNo

Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*

YesNo

Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?*

YesNo

Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?*

YesNo

In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*

YesNo

Have you had a seizure, brain/other nervous system problem or Guillain Barre?*

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 (including acyclovir, famciclovir, valacyclovir)?*

YesNo

Have you received any vaccinations or TB skin test in the past 4 weeks?*

YesNoIf Yes, please list:

Do you have a history of fainting, particularly with vaccines?*

YesNo

For women: Are you pregnant or is there a chance you could come become pregnant during the next month?*

YesNo

Have you received monoclonal antibody treatment for COVID19?*

YesNo

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Herron Pharmacy LLC, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Form completed by*

First NameLast Name

Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)

Signature of Pharmacist

Signature/Title of Immunization Administrator

Today's Date

MonthDayYear

Days for Age Calc

Edencrest Adel Immunization Consent Form October 7th 9-11am

Billing Information

Please input each of the following from your insurance card

For Patients:

Consent to Vaccination

Pharmacy Use Only