Vaccine Immunization Consent & Administration
Select your appointment time and complete prior to arriving for your appointment.
Patient Name
*
First Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date - Moderna and J&J 18+; Pfizer is 12+
Gender
*
Male
Female
Home Phone Number
*
Cell Phone Number
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
example@example.com
Primary Care Provider (PCP) Name
First Name
Last Name
Insurance
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.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Medicare Beneficiaries
Please provide the number on your red, white, and blue Medicare card.
Medicare Number
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
RxBin is the number that tells the pharmacy database which PBM should receive your claim.
RxPCN
Which vaccine do you wish to receive?
Shingles Vaccine
Dose 1
Dose 2
Hepatitis Vaccine
Hep A (adult)
Hep B (adult)
Twinrix (both A & B)
Pneumonia Vaccine
Prevnar 20
Pneumovax 23
Other Vaccines
COVID-19
Influenza (flu), patient age 3 to 64 years of age
Influenza (flu) older than 65 years of age
Polio
RSV
Tdap (Tetanus, Diptheria, Pertussis)
Typhoid (Typhim)
Other
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.
Screening Questions
Please complete all sections
Are you sick today?
*
Yes
No
Do you have a history of fainting, particularly with vaccines?
*
Yes
No
Have you ever had an allergic reaction after receiving a vaccination
*
Yes
No
Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
*
Yes
No
Has any physician or healthcare provider ever cautioned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
*
Yes
No
Have you received any other vaccines or a TB skin test in the last 4 weeks?
*
Yes
No
Do you have a bleeding disorder or are you taking a blood thinner?
*
Yes
No
Do you have a long-term health problem? (choose all that apply)
*
Heart Disease
Lung Disease
Liver Disease
Kidney Disease
Metabolic Disease (e.g. Diabetes)
Asthma
Anemia (or other blood disorder)
NONE
Other
Do you have any of the following Immune System problems? (choose all that apply)
*
Cancer / Leukemia
HIV / AIDS
Rheumatoid Arthritis
Ankylosing Spondylitis
Crohn's Disease
Herpes or cold sores
NONE
Other
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)
*
Yes
No
Have you ever had any of the following Nervous System problems? (choose all that apply)
*
Seizures
Guillain Barre
NONE
Other
During the past year have you received a transfusion of blood or blood products, or have been given immune (gamma) globulin, or antiviral drugs?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
FOR TDAP ONLY - Do you have a cut, injury, puncture, or open wound that prompted you to get a Tetanus shot?
Yes
No
N/A
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
*
Printed name of individual signing this form
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