Short Call/Close/Last Minute Call List for COVID-19 Rankos Pharmacy Immunization Consent Form

I fill my prescriptions at Rankos Pharmacy

Name

First Name Last Name

Date of Birth

mm-dd-yyyy

Address

Street Address

Street Address Line 2

City State

Postal Zip Code

Phone Number

Area Code Phone Number

Email *

example@example.com

Gender

Race

Allergies, sensitivities, health conditions *

Please type no if you don't have allergies, sensitivities, or idiosyncrasies

For vaccine recipients:
The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.

1. Are you feeling sick today? *

Yes No Don't Know

2. Have you ever received a dose of COVID- 19 vaccine? If Yes, see question below *

Yes No Don't Know

If yes to question 2, which vaccine product?

If yes, which vaccine product?

3. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen(r), or for which you had to go to the hospital? *

Yes No Don't Know

- Was the severe allergic reaction after receiving a COVID -19 vaccine? *

Yes No Don't Know

- Was the severe allergic reaction after receiving another vaccine or another injectable medication?

If yes, which vaccine product?

4. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID- 19? *

Yes No Don't Know

5. Have you received another vaccine in the last 14 days? *

Yes No Don't Know

6. Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? *

Yes No Don't Know

7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *

Yes No Don't Know

8. Do you have a bleeding disorder or are you taking a blood thinner? *

Yes No Don't Know

9. Are you pregnant or breastfeeding? *

Yes No Don't Know

Signature

COVID -19 Vaccination Appointment (15 to 30 min. wait required after vaccination).

Front & back of insurance card(s) & Identification card *

Browse Files

rx insurance card & Identification

Rankos Stadium Pharmacy

NPI # 1710092762

101 N Tacoma Ave Tacoma, WA 98403 tel: 253-383-2411 / fax: 253-572-4329

[] Vaccine: Moderna COVID -19 LOT: EXPIRATION: NDC: 80777027310

[] Vaccine: Janssen COVID -19 LOT: EXPIRATION:

Inject 0.5 ml intramuscularly into deltoid now Site: Lt deltoid / Rt deltoid

Immunizer:__________________ Time Administered:________

Substitution Permitted:_______________ Dispense as Written:______________

Elizabeth Rankos, PharmD [] NPI: 1588914428

______________________ ________________

DateTime

Rankos Pharmacy COVID -19 Vaccination Consent Form