Non-Covid Vaccine Consent Form Professional Pharmacy

**PRIOR TO FILLING OUT THIS FORM, PLEASE TAKE PHOTOS OF YOUR INSURANCE CARDS

(Specifically Medicare Part B Red White and Blue) or your commercial insurance cards (pharmacy and medical)***

Which Vaccine are you requesting? *Vaccines occasionally must be ordered in advance of an appt. Please text or call the pharmacy to verify availability.*

*As of 11/10/22 we are currently out of flu vaccine for the year.*

Section I. Personal Information

Patient's Legal Name (This must match your insurance card):*

First NameMlLast Name

Date of Birth:*

Age:*

Cell Phone Number:*

Email:*

Gender:*

MaleFemale

Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer

Race:*

Address:*

Street Address Line 2

Primary Care Doctor:*

Doctor City/State:*

Which arm would you like your vaccine administered in? (Your dominant arm is preferred to reduce soreness).*

LeftRight

Social Security Number*

111-11-1111

Section II. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Has your physician or health care provider ever cautioned or warned you about receiving a vaccine?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug (including acyclovir famciclovir, valacyclovir)?
Have you received any vaccinations or TB skin test in the past 4 weeks?
Would you like us to screen for other vaccines you may be eligible for or need at this time?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:

Section III. Appointment Scheduler

Appointment*

Please read the Vaccine Information Statement (08/06/2021) prior to completeing this form.

Section IV. Signatures

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 applicable . I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Professional Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Professional 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 have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Signature of Person to Receive Vaccine & VIS (or Signature of Parent/Guardian if Patient is < 18 yo) & Signature of Acknowledgment of Notice of Privacy Practices:*

Clear

Please take or upload pictures of front & back of insurance card for billing purposes (Medicare Part B Card, Commerical Insurance or Medicaid Card)*

Medicare Part B (Red, White, & Blue) Card, Medical Insurance, Social Security Card

If Insured by Medicare, please list your MBI number below off of your Red, White and Blue Card.

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

Vaccine Intake Form