Influenza Vaccine Consent Form - (Smith's Drugs of Forest City)

If you have remaining questions, please call us at (828) 245-4591.

Prescribe Wellness: _____

NCIR: _____

Paid (amt): ______

Section I. Personal Information

Patient's Full Name: *

First Name Ml Last Name

Date of Birth: *

Age: *

Phone Number: *

Email: *

Gender: *

Male Female

Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer

Address: *

Street Address Line 2

Mother's Maiden Name

First Name Last Name

Medical Conditions:

Primary Care Doctor: *

Doctor City/State: *

Section II. Questionnaire for Immunization

If you are 65 years old or older, you are eligible for the High-Dose vaccine. Please select which influenza vaccine

High Dose Flu Shot Normal Flu Shot

Please select the correct option below: *

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Have you had the flu shot before?
Do you take any medications that weaken your immune system?
For women: Are you pregnant/nursing or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:

Section III. Appointment Scheduler

**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**

Please pick a day and time for your vaccination *

Section IV. Signatures

I understand the benefits and risks of the influenza vaccine as described in the Vaccine Information Statement (VIS) ( https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html ), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo) *

Clear

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Signature of Acknowledgment of Notice of Privacy Practices: *

Clear

Please take or upload pictures of front & back of insurance card for billing purposes

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Insurance authorization

I authorize the pharmacy to bill my insurance on my behalf for the immunization

State identification number and state of issuance *

Driver's license number and state of issuance *

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.