Immunization Consent Form

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 Buena Vista Drug, 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 accept responsibility for seeking medical attention for any problems associated with my receiving this vaccination. 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. I understand that by signing below I am responsible for payment of this vaccination if my insurance company denies payment to Buena Vista Drug. If the vaccine was paid for by my employer I authorize the pharmacy to share this vaccine history with my employer.

	Yes	No	Don't know or N/A
Are you sick today?
Do you have any allergies to medications, food, eggs, yeast, latex, or a vaccine component?
Have you ever had a serious reaction after receiving a vaccination?
Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?
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?
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?
Have you had a seizure, brain/other nervous system problem or Guillain Barre?
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)?
Have you received any vaccinations or TB skin test in the past 4 weeks?
Do you have a history of fainting, particularly with vaccines?
For women: Are you pregnant or is there a chance you could come become pregnant during the next month?
For Tdap and adult Td: Do you have a cut, injury, puncture or open would that prompted you to get a tetanus shot?
For Shingles (Zoster) vaccine: Have you had a past reaction to gelatin or triple antibiotic ointment?

Immunization Consent Form

Payment

Medicare Part B Insurance Card Information

Colorado Medicaid

Insurance Card Information

Screening Questions

Consent to Vaccination

Pharmacy Use Only