Lehigh General Vaccine Consent Form

GENERAL VACCINE INFORMED CONSENT FORM

This form is NOT for scheduling COVID-19 vaccines.
Patient's Full Name (First MI Last) *
Date of Birth *

Month Day Year
Date
Age *
Address *

Address

Street Address Line 2

City State

Zip Code
Phone *
Gender *

Male Female
Email Address
example@example.com
Primary Care Doctor
Doctor City/State
Would you like us to check your eligibility for other vaccines? *

Yes No
Which vaccine are you wanting to receive? Check all that apply.

Flu Shingles Pneumonia Tdap MMR Hep B Other
Questionnaire
Do you feel sick today? *

Yes No Don't Know
Do you have any allergy to medications foods, or any vaccines? Eggs, gelatin, thimerosal, neomycin, gentamicin, latex, baker's yeast, aluminum, preservatives, etc. *

Yes No Don't Know
Please specify allergy: *
Have you ever had a serious reaction or fainted after receiving any vaccination? *

Yes No Don't Know
Have you ever had a seizure disorder, brain disorder, or Guillain-Barre Syndrome? *

Yes No Don't Know
FOR WOMEN: Are you pregnant or are you planning on becoming pregnant during the next month?

Yes No Don't Know
For children ages 2-4: Has a healthcare provider told you that the child had wheezing or asthma in the past 12 months? *

Yes No Don't Know
For those 50+: Have you had a shingles vaccination or been diagnosed with shingles in the last 12 months? *

Yes No Don't Know
For those 65+: Have you ever had a pneumococcal vaccination? *

Yes No Don't Know
For children/teens: Has the child, sibling, or parent had a seizure; has the child had brain or other nervous system problems? *

Yes No Don't Know
Do you have a long-term health problem with heart, lung, kidney, diabetes, asthma, no spleen, cochlear implant, anemia or a blood/bleeding disorder? *

Yes No Don't Know
Please specify health problem: *
Have you received any immunizations in the past 4 weeks? *

Yes No Don't Know
Please list immunization(s) received: *
Do you have cancer, leukemia, HIV/AIDS, history of a transplant, or an autoimmune disorder? *

Yes No Don't Know
In the past 3 months, have you taken medications that affect immune system such as prednisone, other steroids, or anticancer drugs, drugs for autoimmune disease (RA, Crohn's etc.), or had radiation? *

Yes No Don't Know
During the past year, have you received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin or an antiviral drug? *

Yes No Don't Know
Signatures
Flu Injection VIS Flu Mist VIS Other Vaccine Information Statements can be found by clicking here Notice of Privacy Practices
Acknowledgements

I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent & Release. I have received a copy of the Notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy & of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Person to Receive Vaccine & VIS

Clear
Date

Month Day Year
Date
Parent/Guardian Name
Relationship to patient
Insurance Information

I hereby authorize the pharmacy to bill my Insurance on my behalf for the immunizations and receive payment
Member #
BIN #
PCN #
Should be Empty:

GENERAL VACCINE INFORMED CONSENT FORM

Questionnaire

Signatures