Influenza Vaccine Appointment 2024-2025

Influenza 2024-2025 Vaccination Consent Form

Vaccine Administration Record Professional Pharmacy 9106 Philadelphia Rd # 100 Rosedale, MD 21237-4331

Name of person receiving vaccination*

Appointment*

What gender does your insurance company have you as?*

MaleFemale

Date of Birth*

Date

Address

Street Address Line 2

CityState

Zip

What is your phone number?*

Do you have any allergies to medication? If so, please list them below:

What is your race?

Who is your primary care provider?

What is your primary care doctor's fax number, if available?

What is your mother's maiden name?

What is your email address?

example@example.com

Medicare Number (if applicable):

Are you sick today?*

YesNo

Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?*

YesNo

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?*

YesNo

Have you ever had a serious reaction after receiving a vaccination, including fainting or feeling dizzy?*

YesNo

Have you had a seizure, brain or other nervous system problem or Guillain Barre?*

YesNo

For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNo

Consent

I have read, or have had read to me, the written information regarding the vaccine(s) I will be receiving. 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 current Vaccine Information Sheet. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Professional Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Professional Pharmacy, 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 vaccines.

I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Signature*

Date*

Date

Optional: Please provide a copy of your prescription insurance card to help expedite your appointment