Pharmacy Vaccine Consent Form

Name *

First Name Last Name

Date of Birth *

Month Day Year

Phone Number

Area Code Phone Number

Vaccine(s) to receive? *

Influenza Pneumonia (Prevnar or Pneumovax) Shingles (Shingrix) Tetanus/Pertussis (Tdap - whooping cough)

Primary Care Provider (PCP) Name

First Name Last Name

PCP Phone Number

Area Code Phone Number

Are you sick today? If unsure, call ahead and ask. *

No Yes

Do you have any allergies to medications, food, latex, or a vaccine component? If Yes, use text box to list all allergies. *

No

Have you ever had a serious reaction after receiving a vaccination? If Yes, use text box to explain. *

No

Are you, or anyone in your home, or anyone you take of, being treatedwith chemotherapy, radiation for cancer, have HIV/AIDS or any immunedeficiency disorder? If Yes, use text box to explain. *

No

Have you had Immune (gamma) Globulin or a transfusion of blood orplasma in the past year? *

No Yes

Have you had Guillain-Barre Syndrome, a condition which causesparalysis? *

No Yes

For Women: Are you pregnant or planning a pregnancy In the next threemonths? *

No Yes

Are you taking any blood-thinning medications (i.e. aspirin, warfarin, etc.)? If Yes, use text box to explain. *

No

Form completed by?

First Name Last Name

Signature

Clear

Consent to Vaccination

I have read, have had read to me, and/or was/will be provided the Vaccine Information Statement (VIS) indicated below. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s) marked above. I authorize the information to be forwarded to my primary care physician, authorizing physician, or Department of Health as applicable. I agree to stay in the general waiting area for 15 minutes after receiving my vaccination in case any immediate reactions occur. I understand that if I experience any side effects it will be my responsibility to follow up with my physician at my expense. I hereby release Logan Primary Pharmacy, Family Drug, Calcaterra Drug Co. of Carterville, Inc. and any parent, subsidiary or affiliates, and its officers, employees and agents, respectively, from any and all liability that might arise from this vaccination on behalf of me, my heirs, and personal representatives.

For Patients: The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today, but we may require additional questions or even a prescription authorization from your prescriber. If a question is not clear, please ask us to explain it.