Immunization Consent Form

**** Please do not fill this form out until it is the day you want to come for the vaccine, or the information will no longer be accurate ****

** If this is your first time receiving a vaccine from us, please also fill out the HIPAA Card**

Patient Name*

First NameLast Name

Date of Birth*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

The MIIS (Massachusetts Immunization Information System) is an electronic medical record for immunizations. Because of this system, we no longer fax providers records of immunizations. If you would like to opt out, let us know and we can give you the required paperwork.

Which vaccine are you interested in receiving?

Tdap (Boostrix) VaccinePCV20 (Prevnar 20) VaccineShingles (Shingrix) VaccineRSV (Abrysvo) Vaccine

In which arm would you like to receive the vaccine?

Left ArmRight Arm

Please read the VIS (Vaccine Information Statements) that corresponds with the vaccine you would like to receive.

Tdap (tetanus, diphtheria, pertussis) Vaccine: What You Need to Know

PCV 20 (Prevnar 20) Vaccine: What You Need to Know

Shingles (Shingrix) Vaccine: What You Need to Know

RSV (Abrysvo) Vaccine: What You Need to Know

1. Did you read the Vaccine Information Statement (above)?*

YesNo

2. Are you sick today (the day you are receiving the immunization) with a fever?*

YesNo

3. Are you allergic to yeast, eggs, latex, neomycin, or gelatin?*

YesNo

4. Have you ever had a serious reaction after a vaccination?*

YesNoOther

If so, which vaccine?

5. Do you have heart disease, lung disease, asthma, kidney disease, diabetes), anemia or a blood disorder?*

YesNo

6. Do you have cancer, AIDS/HIV, or compromised immune system?*

YesNo

7. Have you ever had Guillain-Barre Syndrome?*

YesNo

8. Do you have active tuberculosis?*

YesNo

9. Do you have thymus disorder?*

YesNo

10. Do you take prednisone or other steroids, anti-cancer drugs, chemotherapy or have you had X-ray treatments recently?*

YesNo

11. Have you had a seizure, brain or nerve problem?*

YesNo

12. During the past year, have you received a blood transfusion, blood products, or been given immune (gamma) globulin?*

YesNo

13. Are you pregnant/is there a chance you could be pregnant?*

YesNo

14. Do you have contact with pregnant women, newborns, or people with compromised immune systems?*

YesNo

15. Have you received any vaccinations in the past 4 weeks?*

YesNo

If so, which vaccine?

Form completed by*

First NameLast Name

A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of any vaccine causing serious harm, or death, is extremely small. Local symptoms may include: slight tenderness, redness, itching or swelling at the site of injection. Systemic symptoms may include: fever, malaise and muscle pain. These reactions usually begin 6 to 12 hours after immunization and can persist for a few days. Signs of an allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat, or dizziness within a few minutes to a few hours after the shot. In the case of a severe reaction including the symptoms above, or a high fever, behavior changes or flu-like symptoms that occur after vaccination, see a doctor right away.

I certify I have not yet received this vaccine, or I am receiving this vaccine as a subsequent shot in the vaccine series. If I am unsure of my vaccination history, I will contact my physician, and will not hold Letourneau’s Pharmacy responsible for duplicate vaccination. I have read the adverse reactions associated with the administration of vaccines. I have received a copy of the Vaccine Information Statement(s) for the vaccine(s) administered to me today. A copy of the vaccine manufacturer’s drug information sheet is available on request. I have had an opportunity to ask questions about these immunizations. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization(s) or the receipt of the immunization(s) by the person named below for whom I am the legal guardian (‘Ward’). My (or my Ward’s) medical record may be shared with my (or my Ward’s) physician or other healthcare provider. I am requesting that the immunization(s) be given to me or my Ward. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release the pharmacy, and its affiliates, subsidiaries, divisions, directors, contractors, agents and employees (collectively “Released Parties”), from any and all claims arising out of, in connection with or in any way related to my receipt and the receipt by my Ward of this or these immunization(s). Neither the pharmacy nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable, responsible or any way accountable for any loss, injury, death or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described above. The pharmacy will use and disclose your personal and health information or the personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed Notice of Privacy Practices, available upon request, to help you better understand our policies in regard to you and your Ward’s personal health information.

Signature of Patient

Date

MonthDayYear

Signature of Immunizing Pharmacist / Date