Immunization Consent Form

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State

Zip Code

County of Residence enter county here *

Sex *.

Ethnicity *

Race *

Phone Number *

Please enter a valid phone number.

Date of Birth *

Date

Mothers Maiden Name

Required to ask for NY State immunization registry (NYSIIS)

Doctors Name

First Name Last Name

Doctor's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

1. Are You Sick Today? *

Yes No

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

Yes No

If you have allergies please list:

Example: Penicillin, Latex, Eggs, Polyethylene glycol

3. Have you ever had a serious reaction after receiving a vaccination? *

Yes No

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 caner, leukemia, HIV? AIDS or any other immune system problem? *

Yes No

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? *

Yes No

6. In the past 3 moths, 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? *

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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 Vaccine Shingles Vaccine Tdap Covid-19 (Moderna Vaccine) Covid-19 (Johnson & Johnson)

Have you ever RECEIVED a previous vaccination for Covid-19? *

YES NO

What Covid-19 vaccine did you previously have administered?

Moderna Johnson & Johnson Pfizer N/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

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: *

Yes No

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.

Administration Date

Date

Vaccination blank

Administration Site

Left Deltoid Right Deltoid

Dosage

0.5mL .25mL Other

Manufacturer: blank

Lot Number:

lot number

RPh Signature

Clear

Maggy Pharmacy Electronic Vaccination Consent Form

Area Below to Be Completed by Pharmacist