Vaccine Immunization Consent & Administration
Select your appointment time and complete prior to arriving for your appointment.
Date of Birth
Date - Moderna and J&J 18+; Pfizer is 12+
Home Phone Number
Cell Phone Number
Street Address Line 2
District of Columbia
Primary Care Provider (PCP) Name
By completing this form, you are providing consent for Hartzell's Pharmacy to bill your insurance for the administration of your vaccine. Please note that if you do not have insurance coverage or your insurance requires a co-payment, you will be responsible for payment.
Do you currently have health insurance (commercial coverage, Medicaid, Medicare, etc)?
Yes - please complete information below
No - by choosing no you attest that you DO NOT have current coverage.
Social Security Number
This field is required. Used for insurance verification and/or billing.
Please upload a photo of your PHARMACY and MEDICAL insurance card here. Front and back of card is needed.
Drag and drop files here
Choose a file
Please provide the number on your red, white, and blue Medicare card.
Medicare Number (MBI) has 11 alphanumeric characters and can be found on your Red, White, and Blue Medicare Card.
Commercial Insurance or Medicaid
Pharmacy Member ID
Rx Group Number
RxBin is the number that tells the pharmacy database which PBM should receive your claim.
Which vaccine do you wish to receive?
Hep A (adult)
Hep B (adult)
Twinrix (both A & B)
Influenza (flu), patient age 3 to 64 years of age
Influenza (flu) older than 65 years of age
Tdap (Tetanus, Diptheria, Pertussis)
We will attempt to bill vaccines to your pharmacy insurance. Any vaccine and administration fees not covered will be the financial responsibility of the patient.
I acknowledge that I am responsible for any vaccine or administration fees not covered by my insurance.
Please complete all sections
Are you sick today?
Do you have a history of fainting, particularly with vaccines?
Have you ever had an allergic reaction after receiving a vaccination
Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
Has any physician or healthcare provider ever cautioned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
Have you received any other vaccines or a TB skin test in the last 4 weeks?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a long-term health problem? (choose all that apply)
Metabolic Disease (e.g. Diabetes)
Anemia (or other blood disorder)
Do you have any of the following Immune System problems? (choose all that apply)
Cancer / Leukemia
HIV / AIDS
Herpes or cold sores
In the past 3 months, have you taken any medications that weaken your immune system? (e.g. Cortisone, Prednisone, other steroids, anti cancer drugs, or radiation treatments)
Have you ever had any of the following Nervous System problems? (choose all that apply)
During the past year have you received a transfusion of blood or blood products, or have been given immune (gamma) globulin, or antiviral drugs?
Are you pregnant or breastfeeding?
FOR TDAP ONLY - Do you have a cut, injury, puncture, or open wound that prompted you to get a Tetanus shot?
Consent to Vaccination
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hartzell's Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I have read and reviewed the Notice of Privacy Practices available at www.hartzells.com.
Signature of Person Receiving the Immunization or Legal Guardian
Printed name of individual signing this form
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