Vaccination Consent Form

Vaccination Consent Form

We are able to vaccinate 6 years and older. Every person getting vaccinated needs a consent form done - parents/guardians: please fill one out for your minors! We look forward to serving you. Please call 608-256-8712 with any questions! **Please note: we provide the Pfizer COVID-19 vaccine**
**GHC Patients**

Your insurance will NOT pay for vaccines through us. You must get them from GHC, Hyvee, or Costco. You may opt to pay cash through us if you choose. Please notate that on your appointment if you are planning on paying out of pocket!
Patient Name

First NameLast Name
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current patient of Neuhauser Pharmacy?
If you are not a current patient of our pharmacy, please upload an image of your insurance card. This will help with ensuring the process goes smoothly the day of your appointment. Thanks!

**Medicare patients - please upload a photo of your red, white, and blue Medicare card if you are new to us!**
Insurance card photo (if applicable)

Cancelof
Please indicate which vaccines you/your minor are getting this appointment:
I have read or been offered the current Vaccine Information Statement(s) prior to my vaccination. I have had a chance to ask questions and understand all the risks and benefits involved, and request and authorize Maren Rasmussen, RPh, or William D. Bowen, RPh, to administer the vaccine(s) to me or my child.

I agree to stay in the general area for 10 minutes after receiving my vaccination(s) to ensure that no immediate reactions occur. I understand that if I experience any side effects, it will be my responsibliity to follow up with my physician at my expense.

I hereby release Neuhauser Pharmacies, Inc. and its employees from any and all claims and causes of action that might arise or occur to me by reason of administration of the vaccine(s).

I give my permission to share my immunization records with teh Wisconsin Immunization Registrty for the purpose of maintaining a complete and accurate record to assist in assuring full immunization.
Links to respective Vaccine Information Statements (VIS):

COVID-19, HPV, Influenza, MMR, Pneumonia, RSV, Tdap, Shingles
Patient or Parent/Guardian Signature
Date

MonthDayYear
Date
Screening Questions

Please fill out for each person getting a vaccine. We need a separate screening form for each patient. If it is for a minor, please answer for them to the best of your ability.
Are you sick today?
Do you have any allergies to medications, food, vaccine components, or latex?
Have you every had a serious reaction to a vaccine?
Do you have any of the following: a long-term health problem with heart, lung, kidney, or metabolic disease, asthma, a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak?
Are you on long-term aspirin therapy?
Do you have cancer, leukemia, HIV/AIDs, or any other immune system problem?
Do you have seizures or other nervous system problems?
Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or had Multisystem Inflammatory Syndrome (MIS-C) after an infection with the virus that causes COVID-19?
Have you received any other vaccines in the last 4 weeks?
Have you ever felt dizzy or faint before, during, or after a vaccine?
Females only: Are you pregnant?
Should be Empty:

Vaccination Consent Form

**GHC Patients**

Screening Questions

GHC Patients