• Rankos Pharmacy COVID -19 Vaccination Consent Form

  • I have used the WA Phase finder tool and am in the following phase*

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  • 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.

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  • 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             

    ______________________       ________________                                      

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