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

  • Vaccine Consent Form (Family Pharmacy)

    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
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  • *Vaccine eligiblity status will be evaluated by one of our Pharmacists prior to or at your appointment for ConnectRX members


  • Section II. Questionnaire for Immunization
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  • 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.

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  • 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)

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