*IMPORTANT*
Please come at your scheduled appointment time.
Immunization Consent Form and Appointment Scheduler
Please complete prior to arriving for your appointment.
Vaccination With Walberg Family Pharmacies
Patient Name
*
First Name
Middle Name
Last Name
Suffix
Last Name (re-enter)
*
Date of Birth
*
-
Month
-
Day
Year
Date
Date today
-
Month
-
Day
Year
Date
Age
Parent/Guardian completing form if the patient is under 18 years of age
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Which Vaccination(s) were you interested in receiving at your appointment? Check all that apply
*
COVID-19- Spikevax Vaccine (Moderna)
COVID-19 Comirnaty Vaccine (Pfizer)
Hepatitis A Vaccine
Hepatitis B Vaccine
Human Papillomavirus Vaccine (HPV)
Influenza (FLU) vaccine
High Dose Influenza (FLU) vaccine- for 65+
Meningococcal ACWY
Meningococcal ABCWY
Meningococcal B
Pneumonia Vaccine- CAPVAXIVE
Pneumonia Vaccine- Pneumovax 23
Pneumonia Vaccine- Vaxneuvance
Pneumonia Vaccine- Prevnar 20
RSV
Shingles (Shingrix Vaccine)
Tetanus-Diptheria (Td) Vaccine
Tetanus- Diptheria Pertussis (Tdap) Vaccine
Date of Last COVID-19 Vaccine
Date of Last Shingrix Vaccine
Date of Last Pneumonia Vaccine. Which Pneumonia Vaccine did you receive?
Ex Prevnar 13, Pneumovax23
Notes for your Pharmacist
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Patient Consent For Vaccination
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Care Provider (PCP) Name
First Name
Last Name
Insurance Information
By completing this form, you are providing consent for Walberg Family Pharmacies to bill your insurance for the administration of the vaccinations. Please bring all insurance cards at time of appointment.
Insurance Information
*
Commercial Insurance
Medicare
I do not have Insurance
Insurance Information. Please bring insurance card with you to your appointment
Medicare Part A/B ID number (Red, White and Blue Medicare card)
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Consent Questions
Please complete the following questions.
1. Are you sick today?
*
Yes
No
2. Do you have allergies to medications, food, eggs, a vaccine component (ex: Neomycin, Formaldehyde, Gentamicin, Polyethylene glycol, thimerosal, gelatin, yeast or latex)?
*
Yes
No
3. Have you ever had a serious reaction after receiving a vaccine?
*
Yes
No
4. Do you have a long term health problem such as heart, lung, kidney, metabolic disease (Diabetes) asthma, anemia or other blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak?
*
Yes
No
5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problems?
*
Yes
No
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?
*
Yes
No
7. Have you had a seizure, brain, or other nervous system problem or Guillian Barre?
*
Yes
No
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 or valacyclovir)?
*
Yes
No
9. Have you received any vaccinations in the past 4 weeks?
*
Yes
No
10. Do you have a bleeding disorder or are you taking a blood thinner?
*
Yes
No
11. Are you pregnant or is there a chance you could become pregnant during the next month or breastfeeding?
*
Yes
No
12. Do you have a history of any of the following (check all that apply)
Myocarditis or Pericarditis
Multisystem Inflammatory Syndrome (MIS-C or MIS-A)
Immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as Heparin induced thrombocytopenia (HIT)
Thrombosis with thrombocytopenia syndrome (TTS)
Guillain-Barre Syndrome (GBS)
13. Have you ever felt dizzy or faint before during or after a vaccine? Are you anxious about getting a vaccine?
*
Yes
No
You marked Yes to a question above. Please elaborate or place any notes to the pharmacist here
Consent for Vaccination
I have read, or have had read to me, the written information regarding the vaccines 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 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 Walberg Family Pharmacies, 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. Parent or guardian must be present at time of vaccination. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I have read and reviewed the Notice of Privacy Practices available at www.walbergfamilypharmacies.com.
Form completed by
First Name
Last Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)
*
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Which Walberg Family Pharmacy is your preferred choice to be vaccinated at?
*
Clarion Pharmacy
Farrell Pharmacy
Franklin Pharmacy
Greenville Pharmacy
Herbert's Pharmacy
Hermitage Pharmacy
Jamestown Pharmacy
Linesville Pharmacy
Mercer Pharmacy
New Castle Pharmacy
Petrolia Pharmacy
Reynolds Pharmacy
Sharon Pharmacy
Vandergrift Pharmacy
Appointment
*
Submit
Pharmacy Use Only
Vaccine Administration information
Rows
Vaccine #1
Vaccine #2
Vaccine #3
Vaccine(s) Administered
Product Name
MFG
LOT
Expiration Date
Dose, ROA, Injection Site
Date Administered
Date of VIS
Person Receiving VIS
Date VIS received
Signature of Immunizer
Should be Empty: