Vaccine Consent Form - Holland Center Pharmacy

Section I. Personal Information

Patient's name *

First name Last Name

Date of Birth: *

Address: *

Street Address Line 2

Phone Number: *

Email: *

Gender: *

Male Female Unknown Non-Binary

Primary Care Physician Name

Primary Care Physician Phone#

Phone Number

Primary Care Physician Fax #

Fax Number

Please select the Vaccine requested: *

Shingrix ( For Age 50 and older) Tdap ( For Age 18 and older)

Section II. Questionnaire for Immunization

Please select the correct option below: *

	Yes	No	Don't know or N/A
Are you Feeling Sick Today? ( Do you have fever, diarrhea, or have your vomited? )
Have you ever had a severe reaction to any vaccine in the past?
Have you received any vaccine in past 4 weeks?
Do you have allergies to medications, food, a vaccine component, or latex? Examples: Eggs, Gelatin, Thimerosal, Neomycin, Gentamicin, Yeast
Have you had a seizure or a brain disorder or other nervous system problem?
Do you have gullain-barre syndrome? (a condition that causes paralysis)
Do you have any other chronic health conditions like asthma or diabetes?
Do you have cancer, Leukemia, HIV, active shingles or any other immune system problem?
Do you take prednisone, oral steroids, anticancer or antiviral drugs or medications that affect the immune system?
During the past year, have you received a transfusion of blood or blood products, been given a medicine called immune(gamma) globulin, or had radiation therapy?
For women: Are you pregnant or is there a chance you could become pregnant in the next month?
Have you had a pneumococcal vaccine? (Prevnar or Pneumovax)

Please specify your allergies if you have answered Yes to allergies question:

Section III. Appointment Scheduler

Please pick a date and time for your dose *

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.

Signature of Person (authorized Parent/Guardian) to Receive Vaccine and VIS *

Clear

Medicare ID # *

Please upload pictures of front side of your PHARMACY Precription card or MEDICARE Card *

Browse Files

(Vaccine is free, Vaccine administration cost is fully covered by insurance)

Please upload pictures of Back side of your PHARMACY Precription card or MEDICARE Card *

Browse Files

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

Vaccine Consent Form and Screening Questionnaire