Vaccine Consent and Administration Record - VN Pharmacy

  • Patient Information (Vaccine Recipient)

  • Date of Birth*
     / /
  • Gender*
  • Format: (000) 000-0000.
  • Race*
  • Ethnicity*
  • Select the vaccines you would like to receive

  • Doctor/Primary Care Information

    We will send vaccination information from this visit to your doctor/primary care provider using the contact information provided below.
  • Format: (000) 000-0000.

  • Screening Questions

  • 1. Are you sick today? (For example: a cold, fever, acute illness)*
  • Today's date if you are sick today.
     - -
  • 2. Have you been diagnosed with or tested positive for COVID-19 in the last 14 days?*
  • 3. In the past 14 days have you been identified as a close contact to someone with COVID-19?*
  • 4. Do you have allergies to latex, medications, food, or any vaccine? (examples: polyethylene glycol,polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)*
  • 5. Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?*
  • 6. Do you take anticoagulation medication? (For example: Warfarin, Coumadin or other blood thinners)*
  • 7. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?*
  • 8. Have you had a seizure, brain, or other nervous system problem?*
  • 9. Do you have any chronic health condition such as cancer, chronic kidney disease, immunocompromised, chronic lung disease, obesity, sickle cell disease, diabetes, heart disease?*
  • 10. Have you received any vaccinations in the last 14 days?*
  • 11. Have you ever received the following vaccinations?
  • Date of last COVID-19 Vaccine
     / /
  • Date of last Pneumonia Vaccine
     / /
  • Date of last Shingles Vaccine
     / /
  • Date of last Whooping Cough Vaccine
     / /
  • 11. Have you ever received the following vaccinations?*
  • 12. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
  • 13. For COVID-19 vaccine only: Have you been treated with antibody therapy specifically for COVID-19 (monoclonal antibodies or convalescent plasma)?
  • Are you receiving any of the following vaccines today? CHICKENPOX, MMR® II, SHINGLES, VAXCHORA®, YELLOW FEVER*
  • 14. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
  • 15. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
  • 16. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
  • 17. Do you have a history of thymus disease (including myasthenia gravis, DiGeorge syndrome or thymoma), or had your thymus removed? (yellow fever only)
  • 18. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)
  • 19. Have you consumed any food or drink in the last hour? (Vaxchora® only)
  • 20. Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days? (Vaxchora® only)

  • Insurance Information

  • Do you have prescription insurance?*
  • Are you the cardholder?
  • Cardholder's DOB
     - -
  • Do you have Medicare?*

  • Please read the following statements and sign and date below.

    Consent for services, HIPAA Privacy Information and Medical Records

    I have been provided with the Vaccine Information Sheet (VIS) and/or been provided with information regarding to the vaccine I am receiving. I understand all the benefits and risks of the vaccine and have had the chance to ask questions regarding it. I voluntarily assume full responsibility for any reactions that may result. I request the vaccine be given to me and authorize and direct this health care provider to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated by this provider (standing order practitioner (Dr.), my Primary Care Physician (PCP), my insurance plan and/or state federal registries, where required for purposes of treatment, payment or other healthcare operations. This only allows this provider to disclose the following medical records: only documents related to the vaccination received today. This authorization will remain in effect until my health care provider discloses my health information to the recipient identified above; my health care provider cannot guarantee that the recipient will not disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. I understand that I may refuse or revoke this Authorization at any time. I understand that this authorization will remain in effect until the term of this authorization expires or I provide a written notice of revocation to my health care provider. The revocation will be effective immediately upon my health care provider's receipt of my written notice. I have acknowledged that I have received the provider's Inc Notice of Privacy Practices which may be provided at my request. For Medicare Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct. I authorize the release of all records to act on this request and I request that payment of benefits be made on my behalf.

  • Date*
     / /
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  • Should be Empty: