• Hospital Discount Pharmacy

  • Vaccine Consent Form

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  • Vaccine(s) to receive?*

  • Have you ever had an allergy or severe reaction to any vaccine that required medical care?*
  • Are you allergic to eggs, Baker's yeast, streptomycin, neomycin, latex, or any other vaccine ingredients?
  • Do you have a fever, diarrhea, or vomiting today?*
  • Have you ever had Guillan-Barre Syndrome?
  • Are you pregnant?*

  • Consent to Vaccination

    I hereby claim that the above information is true and correct to the best of my knowledge. I consent that pharmacists affiliated with [XXX] Pharmacy may administer this vaccine. I have been informed of the risks and benefits of the vaccine via the CDC-issued Vaccine Information Statement (VIS). I give permission to [XXX] Pharmacy to seek compensation through my insurance, if applicable, knowing that my insurance may not fully cover the associated costs of the vaccine and administration. If this occurs, I understand that I am fully responsible for all costs associated with the administration of the vaccine. I also give consent to have this vaccine information shared as necessary with appropriate parties, including my healthcare provider and the immunization registry, [State] Statewide Immunization Information System.
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