KEESEVILLE (In-Store) Influenza &/or Moderna Spikevax 2024-2025 Booster Immunization Consent Form

Appointment*

Please confirm the immunization you wish to receive by checking the box below*

Influenza (FLU)Covid-19 (Moderna Spikevax 2024-2025 Booster) - Ages 12+

Name*

First NameLast Name

Date of Birth*

Date

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Ethnicity*

Race*

Sex*

Mother's Maiden Name (Last Name ONLY)*

Physician's Name OR*

First NameLast Name

Physician Practice Name

Physician or Practice Phone #

Name of Insurance*

Insurance Cardholder ID #*

If over 65 years old, last 4 of SSN or Medicare ID #

1. Are you sick today?*

YESNO

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

YESNO

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

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 disorders?*

YESNO

5. Do you have cancer, leukemia, HIV, AIDS or any other immune system problem>*

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 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

Immunization Agreement
I understand that the pharmacy advises me to remain within the pharmacy at least 20 minutes after the injections for observation. I will notify the pharmacy of any adverse events associated with immunization. Permission is herby granted to Keeseville Pharmacy to release information to my primary care provider, identified above, regarding any vaccinations received today. I agree to be vaccinated today with the Influenza Vaccine.

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 electronicsystem 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.

By signing below, I agree to the reporting of my vaccine administration to NYSIIS

Signature*