Tyson Drugs Inc/G&M Pharmacy Vaccine Consent Form
This consent form will be used to document your vaccination.
Vaccine Recipient Name
Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
Vaccine Recipient Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Primary Care Provider Name
Don't Know/Not Applicable
1. Are you feeling sick today?
2. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
5. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g. diabetes) anemia or other blood disorder?
6. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, herpes, or cold sores?
7. In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
8. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?
9. During the past year, have you received a transfusion of blood products, or been given immune (gamma) globulin or antiviral drug (including acyclovir, famciclovir, valacyclovir)?
10. For women: Are you pregnant or is there a chance that you could become pregnant during the next month?
11. Have you received any vaccinations or TB skin tests in the past 4 weeks?
12. Do you have a history of fainting, particularly with vaccines?
13. For Tdap and adult Td: Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?
14. For Zoster: Have you had a past reaction to gelatin or triple antibiotic ointment?
Consent (must check each box below)
Check to Consent
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required.
I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Submit Consent Form
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