Universal Vaccination Screening & Consent Form

Covid-19Influenza ("flu")ShinglesPneumoniaTetanus (Td or Tdap)RSV

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number (preferably cell phone).

First Name (not required)Last Name

Note: MBI is required for all Medicare eligible patients. Refer to your Medicare Red, White, and Blue card. If you do not have a Medicare card, please enter your Social Security Number in this field.

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan.

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for Uninsured Patients, please provide either (a) a valid Social Security number, (b) state identification number and state of issuance, OR (c) a driver's license number and the state of issuance.

I have read or have had explained to me the information provided in the Emergency Use Authorization (EUA) Factsheet or Vaccine Information Statement about COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me or to the person named above for whom I am authorized to make this request.

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. I on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Dotzler Pharmacies Inc., its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with,or any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Dotzler Pharmacies Inc. to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Vaccination Screening & Consent Form

Patient Information

Screening

Insurance Information

Insurance Card

Consent