Shingles Vaccine Consent Form

Zoster Vaccine Consent Form

Zoster Vaccine Appointment Please Select *

Patient Information (Vaccine Recipient):

Vaccine Recipient's Name *

First Name Middle Name Last Name

Date of Birth *

Date

Gender at Birth

Race

Ethnicity

Vaccine Recipient's Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Vaccine Recipient's Phone Number *

Please enter a valid phone number.

Primary Care Provider Name: *

Emergency Contact Name:

Emergency Contact Relation:

Emergency Contact Phone Number:

Please enter a valid phone number.

Patient's Insurance Information (Vaccine Recipient):

Please note for the zoster vaccine this will be commerical insurance or Medicare Part D information.

Cardholder ID:

Insurance PCN:

Insurance BIN

Insurance RX Group

Zoster Vaccine Screener Questions *

Yes

No

1. Are you feeling ill today or have you been ill within the last 14 days?

2. Have you ever had a serious reaction after receiving a vaccine?

3a. Have you ever had an allergic reaction to a vaccine component? (This would include a severe allergic reaction {e.g. anaphylaxis} that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing)

3b. Have you ever had an allergic reaction to eggs?

3c. Have you ever had an allergic reaction to preservatives such as thimerosal or phenol?

3d. Have you ever had an allergic reaction to latex?

4. Do you have cancer, leukemia, HIV/AIDS, or another immune system concern?

5. Are you taking medications that weaken the immune system (steriods, anticancer medications, radiation treatment)?

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

7. Have you received a vaccine in the past 2 months?

8. Are you pregnant or breastfeeding?

If you answered yes to question #2 please provide more details below (you do not have to fill out this section if you answered no):

If you answered yes to question #4 please provide more details below (you do not have to fill out this section if you answered no):

If you answered yes to question #5 please provide more details below (you do not have to fill out this section if you answered no):

Which Dose of Shringix is this for you (the vaccine recipient)?

If this is your second dose of Shingrix when did you receive your first dose?

Date

Consent (check each box below after reading and signing)

*

I understand the benefits and risks of the Zoster vaccine as described in the Vaccine Information Sheet (VIS) (Click here for the Shingrix VIS), a copy of which I was provided with this Consent Form. 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 Form. I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Fisherville Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I understand that if I experience any sideeffects, it will be my responsibility to follow-up with my primary provider'soffice or at the health center of my choice. By authorizing the administration of the vaccine(s), I also authorize the release of this information to my primary care provider.

Signature *

Clear

Date *

Date