Universal Vaccine Consent Form

Universal Vaccine Consent Form
Appointment *
Vaccine Recipient Name *

First Name Middle Initial Last Name
Vaccine Recipient Physical Address *

Street Address

City State Initials

Postal / Zip Code
Date of Birth *

Month Day Year
Age
Enter age of vaccine recepient
Gender *
Race *
This information is required for vaccine reporting
Ethnicity *
This information is required for vaccine reporting
Primary Care Provider
Optional if you would like us to fax the record to your primary care provider
Vaccine Recipient Phone Number *
Please enter a valid phone number.
Emergency Contact Name *
Relationship to Emergency Contact *
Phone Number of Emergency Contact *
Select which vaccination(s) you would like to receive:**Please call 605-223-9200 to make sure we have the vaccine in stock**

Influenza Hepatitis A & B Hepatitis A Hepatitis B Haemophilus influenzae type B vaccine (Hib) HPV Meningococcal MMR Pneumonia 13 (Prevnar 13) Pneumonia 23 (Pneumovax 23) Polio (IPV) Shingles (Shingrix) Tetanus/Whooping Cough (Boostrix) Chickenpox (Varicella) Other

Vaccine Screening Questions *

	Yes	No	N/A
1. Are you feeling sick today or have a fever?
2. Do you have any allergies to medications, food (eggs), latex, vaccine component (e.g neomycin, formaldehyde, gentamicin, thimersol, bovine protein, phenol, polymyxin, gelatin, baker's yeast or yeast)?
3. Have you ever had a serious reaction to any vaccination, including fainting or feeling dizzy?
4. Have you ever had a health problem with lung, heart, kidney, or metabolic disease (e.g. diabetes, asthma, or a blood disorder?
5. Have you ever had a seizure disorder for which the patient is on seizure medication(s), a brain disorder, Guillain-Barre syndrome (a condition that causes paralysis) or other nervous system problems?
6. Are you pregnant or considering becoming pregnant in the next month?

Other Questions *

	Yes	No	N/A
1. Have you been told you have pre-diabetes?
2. Are you interested in learning how to delay the diagnosis of diabetes?
3. Have you had the Pneumonia Vaccine?
4. Have you had the Shingles Vaccine?
5. Have you had the Tetanus/Whooping cough Vaccine

Medicare Patients *

	Yes	No	N/A
1. Do you have a diagnosis of diabetes?
2. Are you interested in receiving a pair of diabetic shoes through medicare?
3. Have you been diagnosed with Cancer?
4. Would you be interested in a free full panel DNA Cancer screening?

Insurance Information

Rx BIN Number

Rx PCN Number/Processor Control Number

Rx Group Number/GRP Number RX ID Number
Medicare Benefits Number
For Medicare Patients Only. Enter letters and numbers as shown in the image.
Name of Person Completing This Form *
Relationship to Patient (if not patient)
Which arm would you like the vaccination in? *
Acknowledgement Statement
I certify that I am: (a) the patient and at least 18 years of age or (b) the parent or legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Shane's Pharmacy, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its's staff, agents, successors, divisions, affiliates, subsidiaries, officers, director, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that I understand the purposes/benefits of my State’s Immunization registry (“State Registry”) and the Provider may disclose my immunization information to the State Registry. I acknowledge that, depending upon my state’s law, I may prevent the disclosure of my immunization information by the applicable Provider to the State Registry by using the opt-out form. The Provider will, if my state permits, provide me with an Opt-Out form. I understand that, depending on my state’s law, I may need to specifically consent, and to the extent required by my state’s law, by signing below, I hereby do consent to the Provider reporting my immunization information to the State Registry. I understand that even if I do not consent or if I withdraw my consent, my states laws may permit certain disclosures of my immunization information as required or permitted by law. I voluntarily authorize and direct my healthcare provider at Shane's Pharmacy to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated at Shane's Pharmacy, my Primary Care Physician, my insurance and/or state or federal registries, where required, for the purpose of treatment, payment or other healthcare operations. I further agree to be fully financially responsible for any cost sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service.


Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old): *

Clear
Date Signed *

Month Day Year
Date
Should be Empty:

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