• MAC Pharmacy

    Patient Vaccine Administration and Consent form
  • Do you currently have active medical insurance?*
  • Race*
  • Ethnicity*
  • Do you have a primary care physician?

  • Health Screening and Medical History

  • Have you ever had (Please check all that apply)
  • Do you have any allergy to Medication, Vaccine, or anything else?*
  • Please list any allergies
  • Authorize pharmacy to send information to the primary care physician?*
  • Do you have a fever, feel unwell, or have any signs of acute illness today?*
  • Has the person to be vaccinated received antibodies, a transfusion of blood or blood products, been given immune (gamma) globulin, or antivirals in the past year?*
  • Has the person to be vaccinated received any vaccinations or skin tests in the past four weeks?*
  • Has the person to be vaccinated ever had a reaction, fainted, or felt dizzy after receiving a vaccine or has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*
  • Has the person to be vaccinated ever had a seizure disorder for which they are on seizure medications, a brain disorder, Guillain-Barre Syndrome, or other nervous system problems?*
  • Is the person to be vaccinated currently on home infusions, weekly injections (such as Remicade, Humira, Enbrel, Cimzia, Simponi, Simponi Aria, Xeljanz, Orencia, Arava, Actermra, Cytoxan, Rituxan, adalimumab, infliximab or etanercept), high dose methotrexate, azathioprine, mercaptopurine, anticancer drugs, antivirals or radiation treatment, cortisone or high-dose steroid therapy (prednisone >20mg/day or equivalent) for longer than two weeks?*
  • Which of the following apply to you?*
  • Does the person have a new or moderate to high fever?*
  • Does the person have a cough?*
  • Does the person have diarrhea?*
  • Has the person been vomiting?*
  • Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?*
  • Vaccine requested

  • Consent and Authorization

  • • I hereby give my consent to MAC Pharmacy, as applicable, to administer the medications(s) I have requested above. I understand the benefits and risks of receiving this medication and have received, read and/or had explained to me the Vaccine Information Statement and/or Vaccine Patient Fact Sheet for the vaccine(s) I have elected to receive. I acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering healthcare provider. On behalf of myself, my heirs, and personal representatives, I fully release and discharge MAC Pharmacy, its staff, agents, successor, division, affiliates, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising in any way related to the administration of the vaccine(s).

    • I understand, acknowledge, and consent that the administration of this vaccine will be entered into my state’s immunization registry. I understand the purposes/benefits of my state's immunization registry and acknowledge that, depending upon my state law, I may prevent disclosure of my immunization to the state registry with a signed Opt-Out. The Pharmacist has informed me that I may have the right to refuse. I acknowledge that the administration of this vaccine will be reported to any required local, state, or federal health authorities.

    • I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent to the release of medical information when necessary for billing, reimbursement, and medical protocol.

    • I am aware a pharmacist, qualified pharmacy technician or state authorized pharmacy intern, as allowed by law, might be administering this medication.

    • By initialing here, I acknowledge receipt of MAC Pharmacy privacy practive or wellness Notices. I understand that the Notice is subject to change, and I can obtain a current Notice Online at www.macpharmacy.com, or at any local store location. Refusing to initial and acknowledge receipt will have no impact on my treatment.

  • Date Signed*
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