Vaccine Intake Form

**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)***

Section I. Personal Information

Section II. Questionnaire for Immunization

Section III. Appointment Scheduler

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.

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.