• Vaccine Consent Form and Screening Questionnaire

    Holland Center Pharmacy 621 Milford Warren Glen Rd, Milford NJ 08848
  • Section I. Personal Information

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  • Section II. Questionnaire for Immunization

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  • Section III. Appointment Scheduler

  • Consent For Immunization:

    • I have been offered a copy of the VACCINE INOFRMATION STATEMENT (VIS). I have read, or have had explained to me, the information regarding the vaccine(s) marked above. 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 authorize the administration of the vaccine to me or the person named  for whom I am authorized to make this decision.
    • I, for myself, my heirs, and executors release Holland Center Pharmacy LLC DBA Holland Center Pharmacy as the medicare provider, any retail or external site, physician, and employees, from any and all claims arising out of, or in any way related to my receipt of this or these immunization(s) . Holland Center Pharmacy and the aforementioned related parties shall not at any time or any extent be liable or responsible for any loss, injury, death, or damage to be suffered or sustained at any time as a result of this vaccination program. I agree to wait in the vaccination location for approximately 15 minutes for observation after vaccination.
    • I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history.
      I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools, licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3.
    • I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department, or the New Jersey Department of Health( NJDOH). The NJDOH may be contacted at the website or telephone number listed on the website. There is no cost to participate in this program.
    • I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
    • By signing below, you agree to all the terms and conditions describe above.
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  • Submitting the form only confirms your Appointment time. When you arrive at pharmacy, We will bill it to your insurance to make sure Flu Vaccine is covered at our Pharmacy location.

    By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

  • Vaccine Administration (Pharmacist Use ONLY)


    I hereby certify that I have verified the screening questionnaire and consent with the above named patient


    Vaccine: _______________ Dose: ______   Lot # : __________  Exp Date: __________   Manufacture:__________ 

    Injection Site: Left Arm / Right Arm      Route:    IM

    VIS Date of Publication:__________


    Did an Adverse Reaction occur?          Yes            No


    Contacted VAERS 800-822-7967         Date/Time:

    Primary Care Physician contacted:       Yes            No

     

    ________________             _______________                ___________

    Pharmacist Name                  Signature                               Date

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