Influenza Vaccine Consent Form
Appointment
*
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
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Female
Male
Prefer not to answer
Other
Ethnicity:
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Hispanic or Latino
Non-Hispanic/Latino
Unknown
Prefer not to answer
Other
Race
*
African American
American Indian
Asian
Caucasian
Native Hawaiian/ Other Pacific Islander
Prefer not to answer
Other
Primary Doctor Name
First Name
Last Name
Preferred Pharmacy
I am interested in following vaccinations:
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Influenza Vaccine
Other
Screening for Immunization
Does the person to be vaccinated have a fever or illness today?
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Yes
No
Does the person to be vaccinated have an allergy to eggs, latex, or to a component of the vaccine?
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Yes
No
Has the person to be vaccinated ever had a serious reaction to this vaccine in the past?
*
Yes
No
Has the person to be vaccinated ever had Guillain-Barre syndrome less than 6 weeks after vaccination, uncontrolled seizures or any unstable neurological disorder?
*
Yes
No
Has the person to be vaccinated received any vaccines in the past 30 days?
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Yes
No
Is the person to be vaccinated 6 years of age or older?
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Yes
No
Is the person to be vaccinated currently pregnant, breastfeeding, or planning to become pregnant in the next 30 days?
*
Yes
No
Consent for Immunization
I, undersigned, agree with the followings:
*
I certify that the information above is correct and accurate to the best of my knowledge.
I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving.
All my questions concerning the vaccine have been answered to my satisfaction.
I understand the benefits and risks of receiving the vaccine and request that it be given to me.
I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Pharmacy Name :
Madison Apothecary
Pharmacy NPI :
1083248694
Should be Empty: