Flu Vaccine Consent and Screening

Flu Vaccine Consent and Screening

This pharmacy is providing necessary vaccines to you in a safe and convenient setting in order to promote adherence to current immunization guidelines recommended by the CDC and ACIP. It does not take the place of an ongoing relationship with your primary care provider to address ongoing medical issues and other types of preventive care. We are providing your primary care provider with records of the vaccine(s) administered here so that your medical records may be complete, but be sure to take your personal record with you to your next appointment as well.
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Gender

Male Female
Who is your (Primary doctor, nurse practitioner or physician assistant?
Are you sick today?

Yes No
If Yes, Do you Have a (select all that apply)

A Cough Fever Diarrhea Vomiting None of the above
Have you ever fainted or felt dizzy after receiving a vaccine?

Yes No
Have you ever had a reaction after receiving a vaccine?

Yes No
Do you have a long‐term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder?

Yes No
Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long‐term treatment with drugs such as high‐dose steroids, or cancer treatment with radiation or drugs?

Yes No
Do you have allergies to latex, medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)

Yes No
Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain‐Barré syndrome or other nervous system problems?

Yes No
For women: Are you pregnant or considering becoming pregnant in the next month?

Yes No Not Applicable
Please review the statement below confirming your consent for vaccination and provide the information requested. I have read or have had explained to me, the Vaccine Information Statement regarding the vaccine(s) marked below. I understand the risks and benefits, and have been provided an opportunity to ask questions and they have been answered to my satisfaction. I wish to receive the vaccine(s) indicated below and hereby give consent for the pharmacist named below to administer said vaccine and communicate the administration of the vaccine to my primary care practitioner listed below.

For the services furnished to me by this provider, I authorize the release of medical information about me to the Centers for Medicare and Medicaid Services, South Carolina Medicaid, or any other carrier, payor or their agents to determine the benefits payable for related services. Furthermore, I authorized any covered entity to direct payment for such services to the above named provider.
Signature

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform