Downtown Pharmacy Vaccine Screening and Consent Form

Downtown Pharmacy Vaccine Screening and Consent Form
Vaccination Times are as follows (subject to change):

Monday through Friday

10AM to 4PM

Saturday and Sunday

11AM to 4PM
Please Select a Vaccine *

Flu COVID-19 Shingrix (Shingles)

Consent:

I have read, or had explained to me, the Vaccine Information Statement, Vaccine Information Fact Sheet, and/or Patient Fact Sheet about the vaccination. I have been given an opportunity to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described and I certify the information provided regarding eligibility for the vaccine isaccurate. I request that the vaccination be given to me (or the person named above for whom I am authorized to make this request). I waive and release all claims I, or anyone claiming by or through me, now have or may hereafter acquire against Downtown Pharmacy, and their respective directors, officers, employees, and agents for any damage or injuries if I, or the person named above for whom I am authorized to make this request, contract the disease being vaccinated against, other diseases, or suffer any other adverse reactions following administration of this vaccine. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries. I have received a copy of the Patient Bill of Rights.
Signature *

Clear
Today's Date *

Month Day Year
Date
Guardian Name
Relation To Patient
Should be Empty:

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	Yes	No
Have you had any of the following symptoms in the last 14 Days? (Fever, chills, body ache, fatigue, headache, cough, shortness of breath, difficulty breathing, runny/stuffy nose, loss of smell or taste, sore throat, nausea, vomiting, diarrhea)
Have you tested positive for COVID-19 in the past 14 days or have been told to quarantine yourself by any public health authority?
Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any medication, vaccine, injection, or food?
Are you pregnant or considering becoming pregnant?
Do you have a weakened immune system or take medications that can weaken your immune system (immunosuppressants)?
Have you received any other vaccinations within the last 4 weeks?
Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?
Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?
Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving a vaccine?

	Yes	No
Are you 65 years old or older?
Are you 18 through 64 years old AND a resident of a long-term care facility?
Are you 18 through 64 years old AND have underlying conditions that increase your risk of moderate/severe illness or death from the virus that causes COVID-19 and are seeking a booster because the benefits outweigh the risks?
Are you 18 through 64 years old AND are at increased risk for COVID-19 exposure and transmissionbecause of occupational or institutional setting?

	Yes	No
Have you had any of the following symptoms in the last 14 Days? (Fever, chills, body ache, fatigue, headache, cough, shortness of breath, difficulty breathing, runny/stuffy nose, loss of smell or taste, sore throat, nausea, vomiting, diarrhea)
Have you tested positive for COVID-19 in the past 14 days or have been told to quarantine yourself by any public health authority?
Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any medication, vaccine, injection, or food?
Are you pregnant or considering becoming pregnant?
Do you have a weakened immune system or take medications that can weaken your immune system (immunosuppressants)?
Have you received any other vaccinations within the last 4 weeks?
Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?
Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?
Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving a vaccine?

	Yes	No
Have you had any of the following symptoms in the last 14 Days? (Fever, chills, body ache, fatigue, headache, cough, shortness of breath, difficulty breathing, runny/stuffy nose, loss of smell or taste, sore throat, nausea, vomiting, diarrhea)
Have you tested positive for COVID-19 in the past 14 days or have been told to quarantine yourself by any public health authority?
Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any medication, vaccine, injection, or food?
Are you pregnant or considering becoming pregnant?
Do you have a weakened immune system or take medications that can weaken your immune system (immunosuppressants)?
Have you received any other vaccinations within the last 4 weeks?
Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?
Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?
Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving a vaccine?

Downtown Pharmacy Vaccine Screening and Consent Form

COVID-19 Vaccine

Flu Vaccine

Shingrix (Shingles) Vaccine

Patient Information