Immunization Consent Form

Maggy Pharmacy Electronic Vaccination Consent Form
This electronic consent form is to be only filled out if you have already talked with the pharmacist about being able to come in and receive a vaccination. The Pharmacist will inform you when they can administer the vaccination based on availability.

THIS FORM IS NOT USED TO RESERVE A SPOT FOR COVID-19 VACCINATION CLINICS! THERE IS NOT A SCHEDULER BUILT INTO FORM FOR DATE AND TIME OF AN APPOINTMENT.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please enter your Email:
example@example.com
County of Residence enter county here*
Sex *.
Ethnicity*
Race*
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Mothers Maiden Name
Required to ask for NY State immunization registry (NYSIIS)
Doctors Name

First NameLast Name
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. Are You Sick Today?*

YesNo
2. Do you have allergies to medications, food , a vaccine component, or latex?*

YesNo
If you have allergies please list:
Example: Penicillin, Latex, Eggs, Polyethylene glycol
3. Have you ever had a serious reaction after receiving a vaccination?*

YesNo
If you had a reaction to a vaccination please indicate what happened?
Example: Hives, Itching, anaphylaxis reaction requiring use of a Epipen
5. Do you have cancer, leukemia, HIV? AIDS or any other immune system problem?*

YesNo
4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes, anemia, or other blood disorder?*

YesNo
6. In the past 3 months, have you taken medications that affect your immune system , such as prednisone, Other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments?*

YesNo
7. Have you had a seizure or a brain or other nervous system problem?*

YesNo
8.During the past year, have you received a transfusion of blood or blood products or been given immune (gamma) globulin or an antiviral drug?*

YesNo
9. For Women: Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNo
10. Have you received any vaccinations in the past 4 weeks?*

YesNo
List any vaccination received in the last 4 weeks?
Example: Flu, Singles, Covid-19, Pneumonia, Tetanus
Immunization Agreement 1. I understand that the pharmacy advises me to remain within the pharmacy at least 15 minutes after the injections for observation 2. I will notify the pharmacy of any adverse events associated with immunization. 3. Permission is herby granted to Maggy Pharmacy to release information to my primary care provider, identified above, regarding any vaccinations received today.
I agree to be vaccinated today with the following vaccine(s)*

Influenza (Flu Vaccine)Pneumococcal VaccineShingles VaccineTdapCovid-19 (Moderna Vaccine)Covid-19 (Johnson & Johnson)
Have you ever RECEIVED a previous vaccination for Covid-19?*

YESNO
What Covid-19 vaccine did you previously have administered?

ModernaJohnson & JohnsonPfizerN/A I have NOT received a Covid-19 Vaccine
If you have received a Covid-19 vaccination, what was the date of the last shot?
Date found on Immunization Card
How many shots have you had for the Covid-19 vaccine you have received?
1 shot, 2 shots
If you would like to receive a Covid-19 vaccine please attest to what series of shot is needed
First, Second or BOOSTER SHOT
NYSIIS Reporting Our Pharmacy and the New York State Department of Health want to inform you about the Statewide Immunization Information System (IIS) By law, any immunizations given to patients under the age of 19 must be reported into a secure web-based IIS and this electronic system is Called the New York State Immunization Information System (NYSIIS). For patients aged 19 and older, immunizations may be reported to NYSIIS with patient consent. Inclusion of adults will significantly contribute To a fully-developed, population -based database of accurate immunization records, and complete date is essential to developing statewide immunization programs intended to reduce the burden of vaccine preventable disease.
Patients consent to report to NYSIIS:*

YesNo
What arm would you like to use for the vaccination?*
Left or Right
Patient Signature*

Clear
Date
Assignment Of Benefits for Medicare Billing

I assign the right and responsibility to Maggy Pharmacy Inc to bill on my behalf, and accept payment for Medicare DMEPOS products, and services provided to me, the Beneficiary.

I understand that I am responsible to pay any deductible amount applied to the claims and coinsurance, which is 20 percent of the allowable or approved charge for a product or service.

I permit Maggy Pharmacy Inc to release and collect my health information, and other information, as required (and as permitted by the HIPAA Regulations) from my health care provider and Medicare to receive payment from Medicare.

I understand that this form will be maintained and made available to Medicare or its representatives.
Area Below to Be Completed by Pharmacist
Administration Date

MonthDayYear
Date
Vaccination blank
Dosage

0.5mL.25mLOther
Manufacturer:blank
Manufacturer:blank
Lot Number:
lot number
RPh Signature

Clear
Should be Empty:

Maggy Pharmacy Electronic Vaccination Consent Form

Area Below to Be Completed by Pharmacist