Vaccine Consent and Patient Information Form - Creighton Prep
Please fill out one form per patient to the best of your ability. Parent/Guardian Consent required for those under the age of 18. If we require additional information, we will reach out to you before the event. Thank you!
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Ethnicity
Primary Doctor Name (if known)
First Name
Last Name
Any questions regarding potential interactions with current medications?
*
Yes
No
Insurance Information - Insurance card MUST be present at time of administration
*
Commercial or Medicare Part D
Uninsured
Front of Insurance Card (if available)
Back of Insurance Card (if available)
Commercial Insurance (N/A can be used if applicable, blanks must be filled)
*
BIN Number
PCN Number
Rx Group Number
Member/Cardholder ID
Medicare # (if known)
Insured Patients
*
I authorize ViaRx Pharmacy to bill my insurance on my behalf for the immunization. I am aware that the Pharmacy will bill the PBM for all medications, product and services covered by that PBM and that I am responsible for any co-payments that may apply and/or for the payment for all medications, products, and services provided by the Pharmacy that are not covered by the PBM. I hereby acknowledge that I have received a copy of the Pharmacy's notice of Privacy Practices (HIPPA), and understand each respective party's rights.
Uninsured Patients
*
I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan and will be paying cash ($65 for regular dose, $130 for HIGH dose, or $165 for COVID-19 immunization) at time of administration.
Screening for Immunization
Does the person to be vaccinated have a fever or illness today?
*
Yes
No
Which arm shall receive the vaccine?
*
Right
Left
Does the person to be vaccinated have an allergy to eggs, chickens, chicken feathers, thimerosal, latex, or to a component of the vaccine?
*
Yes
No
Has the person to be vaccinated ever had a serious reaction to this vaccine in the past?
*
Yes
No
Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
*
Yes
No
Do you have a long-term health problem such as heart disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes) anemia, or other blood disorder?
*
Yes
No
Do you have cancer, leukemia, HIV?AIDS, or any other immune system problem? Have you ever been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?
*
Yes
No
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
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)?
*
Yes
No
Has the person to be vaccinated ever had Guillain-Barre syndrome less than 6 weeks after vaccination, uncontrolled seizures or any unstable neurological disorder?
*
Yes
No
Has the person to be vaccinated received any vaccines in the past 30 days?
*
Yes
No
For children 6 months - 8 years, have they received 2 or more doses of influenza vaccine since July 2010? ( If no, the child will need to receive 2 vaccines [at least one month apart] for the best protection against flu.)
*
Yes
No
Is the person to be vaccinated currently pregnant, breastfeeding, or planning to become pregnant in the next 30 days?
*
Yes
No
Consent for 2026 CDC Approved 0.5mL IM Influenza virus vaccine or CDC Approved 0.5mL IM Influenza HIGH Dose virus vaccine
I, undersigned, agree with the followings:
*
I certify that the information above is correct and accurate to the best of my knowledge.
I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving. Vaccine Information Statement attached.
I understand the benefits and risks of receiving the vaccine and request that it be given to me.
I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.
Would you like to receive the 2026-2027 Covid-19 vaccine?
*
Yes
No
Date of Administration
*
October 15, 2026
Responsible Party Print Name OR Parent/Guardian
*
First Name
Last Name
Signature of patient receiving vaccine OR Parent/Guardian if patient is under 18 years of age
*
Consent for 2026-2027 Moderna spikevax, 0.5 mL COVID-19, virus vaccine, mRNA
I, undersigned, agree with the followings:
*
I certify that the information above is correct and accurate to the best of my knowledge.
I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving. Vaccine Information Statement attached.
I understand the benefits and risks of receiving the vaccine and request that it be given to me.
I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.
Date of Administration
*
October 15, 2026
Responsible Party Print Name OR Parent/Guardian
*
First Name
Last Name
Signature of patient receiving vaccine OR Parent/Guardian if patient is under 18 years of age
*
Back
Next
Back
Next
Back
Next
Back
Next
Back
Next
Submit
Should be Empty: