Vaccine Consent Form
Family Discount Pharmacy 310 Fairview Ave Ponca City, OK 74601 (580) 762-6335
Appointment
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
Phone Number
*
Social Security Number
*
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Mother's Maiden Name
*
County of Residence
*
Race
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Unknown
Insurance Card (Front)
Insurance Card (Back)
Primary Care Physician
Primary Care Physician Phone
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Vaccine you would like to receive today. Mark All That Apply
*
Flu Vaccine
CV19 SpikeVax (Moderna)
PLEASE INDICATE YES OR NO FOR THE PERSON RECEIVING VACCINE TODAY
*
Yes
No
1. Are you feeling ill today?
2. Do you have allergies to medications, food, latex, or any vaccine?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have any current or ongoing health problems such as heart, lung, thymus, kidney disease, metabolic disease (i.e. diabetes) or blood
disorders?
5. In the past 3 months, have you taken cortisone, prednisone, other steroids, or anticancer drugs or have you had radiation treatment?
6. Have you ever had a seizure or a brain or other nervous system problem?
7. During the past year, have you received a transfusion of blood or blood product or been given immune (gamma) globulin or an antiviral drug?
8. Women: Are you pregnant, trying to become pregnant during the next month, or breastfeeding?
9. Have you received any other vaccinations in the past 4 weeks?
10. Do you currently reside with anyone who is immunocompromised? (Such as cancer, leukemia, AIDS, etc.)
11.
Do you have a fever or above-normal temperature (greater than 100.4 F)?
12.
Are you experiencing shortness of breath or having troubles breathing?
13. Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
14. Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Signature
*
Date
*
/
Month
/
Day
Year
Date
Signature of Parent or Guardian
Date
-
Month
-
Day
Year
Date
Please Print Parent or Guardian Name
First Name
Last Name
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