RSV Form

Respiratory Syncytial Virus (RSV) Vaccine Consent Form
Name

First NameLast Name
Are you a resident of a Long Term Care facility or an employee/staff member ?
Facility Name
Gender
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a photo of Pharmacy Insurance Card

Cancelof
Pharmacy Insurance Card Name
We reserve the right to reject your vaccine if this section is filled out incompletely.
Pharmacy Insurance ID/Policy #
We reserve the right to reject your vaccine if this section is filled out incompletely.
Pharmacy BIN#
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance PCN#
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance Group #
We reserve the right to reject your vaccine if this section is filled out incompletely.
Social Security Number
This helps us obtain your correct insurance information if you provide us with the wrong card.
Allergies:
If no allergies type "NONE"
Any known allergies?
Allergies:
List known allergies
Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers?
Have you received the RSV vaccine before?
If you have received the RSV vaccine in the past, you do not need to receive it again. The Centers for Disease Control and Prevention (CDC) currently recommends it as a single, lifetime dose for eligible adults (people 75 and older, and those 50–74 with certain risk factors). Because the protection lasts for multiple years and it is not an annual shot, you should not get another dose if you have already received it.
YES,I would like to receive the Respiratory Syncytial Virus (RSV) vaccine.
NO, I decline the Respiratory Syncytial Virus (RSV) vaccine.
CONSENT OR DECLINATION AFFIRMATION: I have been offered the Respiratory Syncytial Virus (RSV) Vaccine. I have read or had explained to me the applicable Vaccine Information Statement(s), had the opportunity to ask questions, understand the benefits and risks, and consent to the vaccine(s) selected. If I decline vaccination and a suspected or confirmed outbreak occurs within the facility, I understand I may be required to follow the facility's infection prevention and isolation procedures.
Print Name
Should be Empty: