LD Flu Auth Form

Lawrence Drug & Compounding

Vaccine Screening and Authorization Form

What vaccine are you requesting today?

Immunization Clinic/Site

First Name

Last Name

Gender

Date of Birth

Date

Address

Street Address Line 2

CityState

Zip

Allergies

Race

Primary Care Physician

1. Are you sick today?

2. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?

3. Have you ever had a serious reaction after receiving a vaccination?

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

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn?s disease, herpes, or cold sores?

6. 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?

7. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?

8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma), globulin or antiviral drug (including acyclovir famciclovir, valacyclovir)?

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

10. Have you received any vaccinations past 4 weeks?

I understand and acknowledge per MO DHSS, this vaccine record will be reported to the state ShowMeVax database

Consent

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 Lawrence Drug & Compounding Lab-Ozark, 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 Lawrence Drug & Compounding Lab 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.

Signature

Date

Admin Pharm/Tech/Intern Signature

Date

For Staff use- Site of Admin

Thank You!!!

--> Staff use only.