Universal Vaccine Screening & Consent Form

61 Sparta Ave, Sparta, NJ 07871
Phone: (973) 512-3131 | Fax: 973-512-3336
info@spartarx.com | www.spartarx.com
Hours: Mon-Fri 9am-8pm | Sat 9am-5pm | Sun 9am-2pm
UNIVERSAL VACCINE SCREENING & CONSENT FORM

Please complete this form before your vaccination appointment. Bring your insurance card and photo ID.
Name

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Gender:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Last 4 SSN or Medicare ID# (for eligibility lookup):
Preferred Arm:
Race:
Ethnicity:
WHICH VACCINE(S) ARE YOU HERE FOR TODAY? (Check all that apply)
Vaccine Selection
Other
C HEALTH SCREENING

Check ALL that apply to you. Leave blank if none apply.
★ FLU ONLY — Complete this section
ALL OTHER VACCINES — Continue below:

Other
CONSENT & AUTHORIZATION
ONLY if patient is under 18 — please PRINT below:
Parent/Guardian Name/DOB:
Relationship:
PCP Name:
I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history. I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools, licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3. I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department, or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number listed above. There is no cost to participate in this program.
New Jersey Department of Health Vaccine Preventable Disease Program / P.O. Box 369, Trenton, NJ 08625-0369 / 609-826-4860 (Fax 609-826-4866) / www.njiis.nj.gov / NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS) / CONSENT TO PARTICIPATE
I have reviewed the information provided, had a chance to ask questions, and consent to receive the vaccine(s) selected above. I understand the benefits and risks of vaccination. I authorize Sparta Pharmacy to bill my insurance for the immunization services provided. I will remain in the pharmacy for at least 15 minutes after vaccination for observation.
Patient/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Clinic-If we are coming to YOU, please select the Clinic below
Optional Questions for NEW Customers
1. If you have BENECARD please share your ID# (if applicable) Type a label
2. If you have HORIZON or AETNA as Medical Insurance, please enter the ID Number on your card type ID#
3. Who is the Primary Cardholder?
first name/ last name
Should be Empty:

UNIVERSAL VACCINE SCREENING & CONSENT FORM

WHICH VACCINE(S) ARE YOU HERE FOR TODAY? (Check all that apply)

C HEALTH SCREENING

CONSENT & AUTHORIZATION