• Vaccine Administration Record / Consent Form

  • Gender*
  • Date Of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • "All insurances accepted, except TriCare"

  • CARDHORDER RELATION*
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  • For Patients: The following questions will help us determine which vaccineyou may be given today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

  • SCREENING QUESTIONS

  • 1. Are you sick today?*
  • 2. Have you ever had a serious reaction after receiving a vaccination ?*
  • 3. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?*
  • 4. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
  • 5. Do you have a long-term health problem such as lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia heart disease (Myocarditis or Pericarditis etc...) or a bleeding disorder, a history of blood clots or are you taking a blood thinner?*
  • 6. Do you have a parent, brother or sister with a immune system problem?*
  • 7. In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, etc.. or anticancer drugs or have you had radiation treatments or drugs for rheumatoid arthritis or Chron’s Disease?*
  • 8. Have you had a seizure or a brain or other nervous system problem or Guillain Barre syndrome?*
  • 9. During the past year, have you received blood/blood products, or been given immune (gamma) globulin or antiviral drug ?*
  • 10. Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?*
  • 11. For women: Are you pregnant or is there a chance you could become pregnant during the next month?*
  • 12. Have you received any vaccinations or TB skin test in the past 4 weeks?*
  • 13. Have you ever felt dizzy or faint before, during or after a vaccine shot?*

  • CONSENT

  • 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 MARRAS PHARMA CORP, 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 MARRAS PHARMA CORP 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.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Administration (Pharmacist Use Only)

  • Vaccine Administered
  • Date Administered
     - -
    2 digit month, 2 digit day, 4 digit year
  • Flu Vaccine Site Of Injection
  •  
  • Should be Empty: