Flu Vaccine Consent Form

Doctor fax number: blanks
Date faxed: blank
Flu Vaccine Consent Form

Vohs Pharmacy
Appointment *
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Date of Birth *

Month Day Year
Date
Gender *
Phone Number *
Please enter a valid phone number.
Email
If you would like a confirmation email with your time, please enter your email.
Primary care doctor
Insurance - if you have Medicare, use the Medicare ID number on your red, white, and blue care. If no insurance, please enter N/A in each field. *

Your name on insurance card

ID number

Rx BIN PCN

RX GRP

Screening Questions *

	Yes	No
Do you feel sick today?
Do you have any drug, food, or vaccine allergies?
Have you ever had a serious reaction after a vaccination?
Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain-Barre Syndrome, or any other nervous system condition?
Are you 65 years or older?
For women, are you pregnant or considering becoming pregnant in the month?

Please list any allergies and serious reactions to previous vaccinations. Leave blank if none.
I certify that I am the patient and at least 18 years of age or the parent/legal guardian of the patient. I hereby give my consent to the health care provider of Vohs Pharmacy to administer the flu vaccines. I understand the risks and benefits associated with the above vaccine. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccines. I authorize Vohs Pharmacy to release any medical or other information to my health care professionals or third party payors as necessary to effectuate care or payment. *

Clear

Vaccine (FOR PHARMACY USE ONLY)

	Lot number	Exp. date	Manufacturer	Dosage	Site of injection	VIS date
Afluria
Fluzone HD