Immunization Consent Form
Please have your pharmacy insurance card ready when completing
Please select how you would like to receive the immunization
*
Walk-in to the pharmacy without an appointment and complete your paperwork prior
Schedule an appointment to receive your immunization in the pharmacy
Schedule an appointment to receive your immunization through a community vaccination clinic
Vaccination Clinic
Whitman Senior Center (Monday October 19, 2026)
Town of East Bridgewater (Wednesday September 30, 2026)
Town of Hanson (date TBD)
Sunrise Plymouth Beach ALF (Wednesday September 23, 2026)
The Cordwainer ALF Norwell (Monday October 5, 2026)
Cornerstone of Weymouth (Wednesday October 7, 2026)
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Appointment
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Insurance Card Information
Please input each of the following for your insurance card. If you have both Medicare Part B and Part D please include BOTH. Please bring your insurance card and ID with you.
Bin number
PCN
Rx Group
Identification Number
Medicare Part B Number (if applicable)
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Patient Name
*
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Gender
*
Female
Male
Patient Phone Number
*
Format: (000) 000-0000.
Vaccine(s) to receive?
*
Influenza (over 65 dose)
Influenza (ages 9-64 dose)
Tetanus/Pertussis (Tdap - whooping cough)
Shingles (Shingrix)
Pneumonia (Prevnar or Pneumovax)
COVID-19 (Pfizer-Comirnaty)
RSV
QUESTIONS
For Patients: The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.
Are you sick today?
*
Yes
No
Do you have any allergies to medications, food, eggs, yeast, latex, or a vaccine component?
*
Yes
No
If yes, what is your allergy?
Have you ever had a serious reaction after receiving a vaccination?
*
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
Have you had a seizure, brain/other nervous system problem or Guillain Barre?
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Yes
No
Have you received any vaccinations or TB skin test in the past 4 weeks?
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Yes
No
Do you have a history of fainting, particularly with vaccines?
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Yes
No
For women: Are you pregnant or is there a chance you could come become pregnant during the next month?
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Yes
No
N/A
For Tdap: Do you have a cut, injury, puncture or open would that prompted you to get a tetanus shot?
*
Yes
No
N/A
For Shingles (Zoster) vaccine: Have you had a past reaction to gelatin or triple antibiotic ointment?
*
Yes
No
N/A
For COVID-19: Have you had Myocarditis or Pericarditis within 3 weeks after a dose of any COVID-19 vaccine?
Yes
No
For COVID-19: You should consider delaying the COVID-19 vaccine within 2 weeks before or after a cortisone shot. Have you had a cortisone shot or plan on getting one within 2 weeks of your scheduled vaccine?
Yes
No
Consent to Vaccination
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Duvall Family Drugs, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
Form completed by
*
First Name
Last Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)
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Pharmacy Use Only
Do no complete the below questions
Signature of Pharmacist/Name
Vaccine information (LOT/EXP/SITE)
Should be Empty: