Vaccines Other Than COVID19 for Chapman Drug Website

Consent Form For Vaccines Other Than COVID19

If you are already an established customer at Chapman Drug you don't need to fill out this form. Just walkin or make an appointment on our website. If you are a new patient please fill out the form below. You must have insurance (commercial, medicare, medicaid, etc.). Please bring a copy of your insurance card (front and back). You must be 18 years of age or older.
Vaccination (other than COVID) you wish to receive:*
If you want Covid Vaccine at same visit please fill out other consent form as well. We may contact you to determine the appropriateness of other vaccines prior to the appointment.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender at Birth:*
Address*

Address

Street Address Line 2

CityState

Zip
Primary Phone*
Primary Phone Type:*
Cell Phone:*
Please enter a valid phone number.
Email*
example@example.com
Allergies
Race: *
Ethnicity:*
Primary Care Physician
Physician's Office Phone Number
Mothers Maiden Name*
Screening Questions
1. Are you sick today?*
2. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex? *
3. Have you ever had a serious reaction after receiving a vaccination?*
4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*
5.Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes) anemia or other blood disorder?*
6.Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn?s disease, herpes, or cold sores? *
7.In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? *
8.Have you had a seizure or a brain or other nervous system problem or Guillain Barre? *
9.During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug (including acyclovir famciclovir, valacyclovir)? *
10. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
11. Have you received any vaccinations or TB skin test in the past 4 weeks? *
12. Do you have a history of fainting, particularly with vaccines?*
13. For Tdap and adult Td: Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?
14. For Zoster: Have you had a past reaction to gelatin or triple antibiotic ointment?
Consent:

Ihave 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 Chapman Drug Co., Inc., 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 Chapman Drug Co., Inc. 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.
Name (print):*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Consent Form For Vaccines Other Than COVID19

Screening Questions