Hillcrest Pharmacy Vaccine Consent Form

Hillcrest Pharmacy Vaccine Consent Form

Patient authorization form for vaccination, including screening questions, consent signature, and office administration details.
Patient Information
Patient Name

First NameLast Name
Date of Birth

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider
Social Security #
Screening Questions
Do you have allergies or reactions to any foods, medications, vaccines, or latex?
Please specify your allergies or reactions.
Have you ever had a serious reaction after receiving a vaccination?
Do you have an allergy to eggs?
For women, are you pregnant or is there a chance you could become pregnant during the next month?
Have you received any other vaccinations in the last 4 weeks?
Vaccine (s) Requested

Other
Signature of patient to receive vaccine (or parent, guardian, or authorized representative)
Please read the following statement and sign below on the signature line.I have read or have had explained the information provided about the vaccine I am to receive. I have been given the Vaccine information sheet or the fact sheet corresponding to the vaccine I am being given. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of vaccination and ask that the vaccine be given to me or to the person named above for whom I am authorized to make this request. I understand that if I experience side effects, I should do the following: call the pharmacy, contact the doctor, call 911. I do hereby authorize Hillcrest Pharmacy to release information and request payment. I certify that the information given by me in applying for payment under Medicare, Medicaid or other third party is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Photo of your Insurance Card (s) if available.

Cancelof
Should be Empty:

Hillcrest Pharmacy Vaccine Consent Form

Patient Information

Screening Questions

Signature of patient to receive vaccine (or parent, guardian, or authorized representative)