Lopez Island Pharmacy Vaccination Questionnaire Ver 1.0 7.31.2026

Lopez Island Pharmacy (360) 468-2616 Fax (360) 468-3825

Vaccination Consent Form

rev: 07/31/2026 HIPAA Compliant ver 1.1

Only fill out this consent form AFTER you have made an appointment

UNLESS you are requesting an immediate need, example (Tetanus Vaccination)
Patient Name (Who is receiving the vaccination):

First NameMiddle NameLast NameSuffix
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex:
Phone Number:

Area CodePhone Number
Email:
example@example.com
Race (Required by WA State Registry):
Social Security Number (SSN):
If you are Medicare Eligible we need the Medicare ID off your Red, White & Blue ID Card. Example format: 1BC2-D03-EF45.
************** It is NOT your Social Security Number *******************