Vaccine Consent Form

This pharmacy is providing necessary vaccines to you in a safe and convenient setting in order to promote adherence to current immunization guidelines recommended by the CDC and ACIP. It does not take the place of an ongoing relationship with your primary care provider to address ongoing medical issues and other types of preventive care. We are providing your primary care provider with records of the vaccine(s) administered here so that your medical records may be complete, but be sure to take your personal record with you to your next appointment as well.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age *
Gender *
Address (Street, City, State) *
Primary Care Doctor (Name, Phone # and Fax #) *
Your Phone Number *
List Medication or Food Allergies *
Consent: Please review the statement below confirming your consent for vaccination and provide the information requested

I have read, or had explained to me, the Vaccine Information Statement for the vaccine(s) I am receiving today.

I understand the risks and benefits, and have been provided an opportunity to ask questions, which have been answered to my satisfaction. I wish to receive the vaccine(s) and hereby give consent for the pharmacist to administer the vaccine(s) and communicate the administration of the vaccine(s) to my primary care practitioner listed above and to the state immunization registry.
Signature

Clear
Today's Date *

Month Day Year
Date
Which vaccines are you requesting today? *

Flu Pneumonia (Prevnar-13, Pneumovax-23) Shingles Tdap

Type a question *

	Yes	No
Are you sick today or do you have a fever?
Have you ever had a serious reaction to a vaccine, such as fainting or anaphylaxis?
Do you have any allergies to medications, foods, latex, or any vaccine component?
Do you have any long-term health problems with heart disease, kidney disease, liver disease, nervous system disorders, respiratory disorders (COPD, asthma), blood disorders, or diabetes?
Do you have a weakened immune system because of HIV/AIDS or another disease affecting the immune system, long-term treatment with high-dose steroids, or cancer treatments?
Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain-Barre 6) syndrome or other nervous system problems?
Are you a parent, family member, or caregiver to a newborn infant?
Have you received a tetanus booster in the past 10 years?
For WOMEN only: Are you pregnant or considering becoming pregnant in the next month?

The below form is to be completed by the immunizing pharmacist
Signature of vaccine administrator

Clear
Date vaccine was given

Month Day Year
Date
Name of vaccine and dose #
Injection site
Manufacturer
Lot #
Exp. Date
VIS Date
Should be Empty:

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