COVID Vaccine Consent Form

THIS IS NOT THE CORRECT FORM FOR A COVID-19 VACCINATION (PLEASE RETURN TO WEBSITE)
Vaccine Consent Form (Family Pharmacy)

* Please fill out the required details below. If you have questions, please call us at (803) 649-1776 or (803) 648-1776.
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Social Security Number *
This information allows us to accurately and efficiently locate insurance information to streamline your wait time.
Mother's Maiden Name*
Email:*
Gender:*

MaleFemale
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answer
Address:*

Street Address Line 2
Primary Care Doctor:*
Doctor City/State:*
Are you part of our ConnectRX monthly synchronization program*?*

YesNo
*Vaccine eligiblity status will be evaluated by one of our Pharmacists prior to or at your appointment for ConnectRX members
Which vaccine(s) are you looking to receive on this visit*?:*

Influenza (regular)Influenza (high dose - for those 65 years and older)Pnuemonia (Prevnar 13)Pneumonia (Pneumovax 23)Pneumonia (Prevnar 20)Shingrix (shingles) dose #1Shingrix (shingles) dose #2Tetanus booster (contains pertussis/whooping cough)Hepatitis AHepatitis BHepatitis A&B
Section II. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
Are you feeling sick today?
If sick, do you have a fever?
If sick, do you have a cough?
If sick, do you have diarrhea?
If sick, have you been vomiting?
Have you ever fainted or felt dizzy after receiving a vaccine?
Have you ever had a reaction after receiving a vaccine?
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g. diabetes), or anemia or another blood disorder?
Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs?
Do you have allergies to latex, medications, food or vaccines? (Examples : eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, or thimerosal)
Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain-Barre syndrome, or other nervous system problems?
For Women, Are you pregnant or considering becoming pregnant in the next month?
Are you currently on home infusions or weekly injections (such as Remicade, Humira, Enbrel, Cimzia, Simponi Aria, Xelianz, Orencia, Arava, Actermra, Cytoxan, Rituxan, adalimumab, infliximab, or etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs, or radiation treatments?
Have you received any vaccinations or skin tests in the past four weeks?
Have you received a transfusion of blood, blood products or been given a medication called immune (gamma) globulin in the past year?
Are you currently taking high-dose steroid therapy (prednisone >20mg/day or equivalent) for longer than 2 weeks?

Please specify the allergy, if applicable:
Section III. Signatures I have read or have had explained to me, the Vaccine Information Statement for the vaccine. I understand the risks and benefits, and have had an opportunity to ask questions, which were answered to my satisfaction. I understand the benefits and risks of receiving the vaccine and give consent for the pharmacist at Family Pharmacy to administer the vaccine and communicate the administration to my primary care practitioner (listed above). I acknowledge receiving the pharmacy’s Notice of HIPPA privacy practices.
*NEWBERRY STREET ONLY* - Schedule Appointment
*SOUTHSIDE/PRICE AVENUE LOCATION ONLY* - Schedule Appointment
Please acknowledge here that you have chosen a date/time/location above:*

I have made an appointment.
Signature of Person to Receive Vaccine (or Signature of Parent/Guardian if Patient is < 18 yo)*

Clear
Signature of Acknowledgment of Notice of Privacy Practices:*

Clear
Please take or upload pictures of front & back of insurance card for billing purposes

Browse Files

Cancelof
Authorization:

I authorize the pharmacy to bill my insurance on my behalf for the immunization and the information provided is true and accurate.
If uninsured, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan
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.
*****PHARMACY USE ONLY *****

VACCINE NAME(s): ______________________ DATE VACCINATED: ___________

(PLACE PHARMACY LABEL(S) HERE TO INCLUDE VACCINE NAME, LOT#, EXPIRATION DATE, ETC.)

Method: IM SQ Site : Left Arm Right Arm

SIGNATURE OF PHARMACIST ADMINSTERING INJECTION: _______________

James Watts SC: 6388; Brandi Johnson SC:12608; Tracie Mims SC:9641;

Emily Russell SC:37662; Jess Baughman SC: 36754

Student Initials: _________ Intern#________ (circle supervising RPH above)
Should be Empty:

THIS IS NOT THE CORRECT FORM FOR A COVID-19 VACCINATION (PLEASE RETURN TO WEBSITE)

Vaccine Consent Form (Family Pharmacy)