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  • West Side Pharmacy Vaccination Consent Form

    Benton School District Clinic

  • Section 1: Patient Information

  • Date of Birth:*
     - -
  • Format: (000) 000-0000.
  • Ethnicity:*
  • Race:*
  • Vaccination Needed:*

  • Section 2: Insurance Information

  • Circle one:*

  • Section 3: Screening Questionnaire

  • Have you had any vaccinations within the last 28 days?*
  • Do you have a fever and/or feel sick today? Are you currently being treated for an active infection or illness?*
  • Do you have any allergies to medications, vaccination components, foods, or latex?*
  • Have you ever had an immediate severe reaction to a vaccination or injectable medication? Reaction would have occurred within the first 4 hours following vaccination and required EpiPen use, hospital treatment, swelling of the face and/or throat, fast heartbeat, full body rash, or dizziness.*
  • Do you have any long-term health conditions such as heart disease, diabetes, lung or kidney disease, anemia or other blood disorders, cancer, AIDS, or any other moderate-to-severe immune compromising condition? Have a history of seizures, brain, or nervous system concerns?*
  • Are you using any steroid treatments, anticancer medications, or undergoing radiation treatment or chemotherapy?*
  • Within the past year, have you received a blood transfusion? Do you take blood thinners?*
  • Are you pregnant, breast feeding, or planning on becoming pregnant within the next 3 months?*
  • For Flu Vaccination: If you are 65 years of age or older, would you like to receive the high dose flu vaccine?
  • For COVID-19 and RSV Vaccination: Do you have a medical condition that puts you at a high-risk for severe COVID-19?
  • For other vaccinations requiring multiple doses: Have you already received a dose of the vaccination?
  • If yes, which vaccine did you receive?
  • How many doses have you received?
  • Date Last Received:
     - -
    2 digit month, 2 digit day, 4 digit year
  • RELEASE, ASSIGNMENT, AND INSURANCE AUTHORIZATION: I have received and reviewed the Vaccine Information Statement (VIS) for the vaccine(s) I am receiving today. I understand the benefits and potential risks associated with vaccination and have had the opportunity to ask questions. I voluntarily consent to the administration of the vaccine(s) by an authorized healthcare provider at West Side Pharmacy on Military Road. I acknowledge that I have reviewed a copy of the Provider's Privacy Notice and understand that my vaccination record, including all administration details, will be reported to Arkansas WebIZ, the state immunization registry, as required by law. I understand that I may request a copy of my immunization record at any time. I authorize the release of any necessary medical information to my insurance provider, Medicare, Medicaid, or any other third party payer for the purpose of processing claims related to this immunization. I request that payment of authorized benefits be made directly to West Side Pharmacy on Military Road for services rendered. I understand that I may be financially responsible for any charges not covered by my insurance. This authorization remains in effect for all future immunization services unless I revoke it in writing. I agree to remain in the designated vaccination area for at least 15 minutes after receiving my vaccine (or 30 minutes if I have a history of severe allergic reactions) to allow for monitoring and immediate medical intervention in the event of an adverse reaction. By signing below, I confirm that I have read and understand this consent form, and that the information I have provided is true and accurate to the best of my knowledge.
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