General Vaccine Consent Form

General Vaccine Form

164 5th Ave, Brooklyn, NY 11217
Park Chemists Location*
Park Chemists Street*
Park Chemists Zip Code*
Park Chemists Phone*
Online Scheduling*
Vaccine Options

Select up to 2 vaccines you want to receive
Vaccine Choice 1*
Vaccine Choice 1 - Name *
Vaccine Choice 1 - Manufacturer *
Vaccine Choice 1 - VIS DATE*
Would you like any additional vaccines?*

YesNo
Vaccine Choice 2
Vaccine Choice 2 - Name
Vaccine Choice 2 - Manufacturer
Vaccine Choice 2 - VIS DATE
Vaccine Choices - COVID-19 Related?

YesNo
Which Shingrix dose will this be?*

1st Dose2nd Dose
For the RSV vaccine, you must be 60 years or older, or within week 32-36 gestation of pregnancy. Does either of these apply to you?*

YesNo
You are not eligible for the RSV vaccine.
Which COVID-19 dose will this be?*

3rd Dose4th Dose5th Dose6th Dose
Your vaccine choices are incompatible with each other. Please change your vaccine choices to be different from each other. You cannot pair two different flu shots, two different COVID-19 vaccines, or other choices intended to protect against the same virus.
Does the above scenario apply to you?*

Yes, I meet at least one of the above Moderately or Severely Immunocompromised Criteria.
Does the above scenario apply to you? [OLD]

YesNo
Last-dose Date*

MonthDayYear
Required Last-dose Date Limit*

MonthDayYear
Date

Section - Form Consent
Consent
I authorize Park Chemists to report the administration of this immunization to the Citywide Immunization registry (CIR) and my Primary Health Care Provider.
Recipient / Surrogate / Guardian Signature*

Clear
Submission Date

MonthDayYear
Date
Signee Print Name*
Relationship to Patient, if other than Recipient*
Please verify that you are human*
Which appointment?*

FirstSecond
Vaccine 2: Which arm would you like the vaccination(s) on?
Vaccine 2: Date VIS Given

General Vaccine Form