Universal Vaccine Questionnaire and Consent Form

Name*

First NameMiddle InitialLast Name

Address*

Address

Street Address Line 2

CityState

Zip code

Date of Birth*

Date

Race*

Sex (M/F)*

MaleFemale

Email

example@example.com

Ethnicity*

Phone*

Format: (000) 000-0000.

Allergies*

Insurance ID / Social Security Number*

If you provide SSN for Medicare we can possibly pull the info instead of having card present. (Please bring copy of Medicare Red/White & Blue Card or Insurance Card)

Emergency Contact*

Phone*

Format: (000) 000-0000.

1. Do you or have you in the last 10 days had any of the following: fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting or diarrhea?*

YesNo

2. Have you ever fainted or felt dizzy after receiving a vaccination?*

YesNo

3. Have you ever had a reaction after receiving a vaccine?*

YesNo

4. Do you have allergies to latex, medications, food or vaccines? (Ex: eggs, b-bovine protein, gelatin, gentamycin, neomycin, phenol, yeast, or thimerosal)*

YesNo

5. Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain-Barre syndrome or other nervous system problems?*

YesNo

1. Have you tested positive and/or been diagnosed with COVID-19 in the last 10 days?

YesNo

2. Has the person to be vaccinated received passive antibody therapy for COVID-19 in the last 90 days?

YesNo

3. Do you require an Epi-pen for severe allergic reactions?

YesNo

I acknowledge that I have received, read, and understand the Vaccine Information Statement for the vaccine(s) listed below. I have had the chance to ask questions about the contents of the Vaccine Information Statement. I understand the benefits and risks of the vaccine, and I believe that benefits of receiving the vaccine outweigh the risks associated with receiving the vaccine. I hereby consent to have the vaccine administered to be by the company pharmacist. I understand and agree that this company may be required by applicable law to report certain information without notice to me about my vaccination to the appropriate state and federal regulatory authorities for purposes such as reporting of adverse events or immunization registries. I further agree to hold Prescriptions Unlimited and its subsidiaries, officers, employees, agents, representatives, contractors, successors and assignees from any claim or action arising out of or, in any way incidental to this vaccination.I am 18 years or older, under no duress, and have read and understand this informed consent for the vaccine listed below. I will communicate the information provided to me today about my vaccination to my primary care provider if I have one. By signing below, I certify that I am the patient or the patient's guardian/personal representative signing on behalf of the patient. I read, understand, and agree to all the statements on this form.

Signature of Patient/Legal Guardian/POA*

Date*

Date

Universal Vaccine Questionnaire and Consent Form

VACCINE CONSENT FORM

PLEASE ANSWER THE FOLLOWING FOR ALL VACCINES