Immunization Consent Form
Please have your pharmacy insurance card ready when completing
Please select how you would like to receive the immunization
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Schedule an appointment to receive your immunization in your car (ensure appointment is at least 1 hour in the future when submitting this form)
Walk-in to the pharmacy without an appointment and complete your paperwork prior (wait until you receive a notification on your phone before coming to the pharmacy)
Appointment
*
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Payment
Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
Choose a payment method
*
My insurance is already on file
Pay out of Pocket
Commercial Insurance
Medicare Part D/ Medicare Advantage
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Insurance Card Information
Please input each of the following for your insurance card
Bin number
PCN
Rx Group
Identification Number
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Patient Name
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First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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-
Month
-
Day
Year
Date
Age
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Only can immunize 5 years old and older
Gender
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Female
Male
Race
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Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
Patient Phone Number
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Mother's Maiden Name
*
Utilized for the statewide immunization registry
Vaccine(s) to receive?
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Influenza
Shingles (Shingrix)
Tetanus (Td)
Tetanus/Pertussis (Tdap - whooping cough)
Pneumonia (Prevnar or Pneumovax)
Primary Care Provider (PCP) Name
First Name
Last Name
For Patients: The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.
Are you sick today?
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Yes
No
Do you have any allergies to medications, food, eggs, yeast, latex, or a vaccine component?
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Yes
No
Have you ever had a serious reaction after receiving a vaccination?
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Yes
No
Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
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Yes
No
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?
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Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?
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Yes
No
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?
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Yes
No
Have you had a seizure, brain/other nervous system problem or Guillain Barre?
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Yes
No
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug (including acyclovir, famciclovir, valacyclovir)?
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Yes
No
Have you received any vaccinations or TB skin test in the past 4 weeks?
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Yes
No
Do you have a history of fainting, particularly with vaccines?
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Yes
No
For women: Are you pregnant or is there a chance you could come become pregnant during the next month?
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Yes
No
N/A
For Tdap and adult Td: Do you have a cut, injury, puncture or open would that prompted you to get a tetanus shot?
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Yes
No
N/A
For Shingles (Zoster) vaccine: Have you had a past reaction to gelatin or triple antibiotic ointment?
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Yes
No
N/A
Consent to Vaccination
I have 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 Duvall Family Drugs, 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 this Pharmacy 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.
Form completed by
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First Name
Last Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)
Clear
Email
example@example.com
Appointment
*
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Submit
Pharmacy Use Only
Do no complete the below questions
Signature/Title of Immunization Administrator
Signature of Pharmacist
Should be Empty: