Sharpsburg Pharmacy General Vaccine Consent Form

17316 Shepherdstown Pike
Sharpsburg, MD 21782
p: 301.432.7223 - f: 301.432.4423
www.sharpsburgpharmacy.com

Thank you for your interest in scheduling a Vaccination at Sharpsburg Pharmacy! This form is used to schedule all vaccines appointments except COVID-19. Patients must be at least 9 years of age for us to administer the flu vaccine and most other vaccines can be given to adult patients without a prescription. The current state of emergency order grants us the ability to give certain vaccines to younger patients so please call if you need a vaccine for a child younger than 9 years of age. Per Maryland law, we are only allowed to give vaccines as indicated on one of the CDC Vaccine schedules. The child and adult schedules can be found here and the travel destination recommendations can be found here. Please call if you have any questions about which vaccines are recommended for you or if you need a vaccine not listed below.

To view the Vaccine Information Sheet (VIS) for your chosen vaccine please click here and scroll down to find a listing of individual vaccines. We will also print a copy for you the day of your appointment.

If all the appointment times below are grayed out, they have been taken.

We recommend that you make a NOTE of your APPOINTMENT Date and Time and DOWNLOAD/PRINT the PDF form for your records once you hit submit. You may do this on the "Thank You" page that appears after your form is submitted successfully. Please bring this and any insurance cards with you for your appointment. An email confirmation of your appointment will be sent but many email providers send Jotform emails to their spam or junk mail folders. Please check these folders before calling the store to confirm.

If you need to cancel an appointment please call us so that we can open the spot up for someone else. Please help us reach as many patients as possible by keeping your appointment time or giving us plenty of notice if you can't.

Available Appointments*

I am registering for:*

Which arm would you like us to use for your vaccination?*

I would also like a second vaccination at this appointment: (optional)

**This 2nd vaccination will be given in the opposite arm chosen above. If this is not possible please let a staff member know**

Name*

First NameLast Name

Patient Email Address*

Date of Birth*

Date

Mother's Maiden Last Name*

Required by Maryland ImmuNet (State of Maryland Vaccine Registry)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender*

Cell Phone Number*

Please enter a valid phone number.

Primary Care Provider (if applicable)

Primary Care Provider City / State (if applicable)

Primary Care Phone # (if known)

Please enter a valid phone number.

Race*

Ethnicity*

Have you Screening Questions - if you answer "yes" please include details in the comment section*

	YES	NO	Unsure
Do you feel sick today?
Do you have allergies to medications, foods, vaccines, or any other products?
Have you ever had a severe allergic reaction after receiving a vaccine?
Have you received another vaccine in the last 30 days?
Do you have a long term health problem such as heart disease, lung disease, asthma, kidney disease, anemia, or a blood disorder?
Have you been diagnosed with having a seizure, brain, or nerve problem?
During the past year, have you received a transfusion of blood, blood products, or been given a medication called immune (gamma) globulin?
Do you have a weakened immune system caused by a medical condition (HIV, AIDS, leukemia, cancer, etc) or are you taking immunosuppressive drug therapy (cortisone, prednisone, other steroids, or anti-cancer drugs)?
Are you pregnant (or think you may become pregnant in the next month) or breastfeeding?

Comments to any Yes Answers

*Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I consent to the staff to adminster the vaccination(s) mentioned below. I have reviewed the Vaccine Information Sheet (VIS) available here for the vaccine I am receiving. I understand the benefits and risks of receiving this vaccine and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations and their officers and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this vaccine. I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist so that I may receive treatment if I begin to feel unwell.

Signature*

Clear

Date Signed*

Date

Many vaccinations are covered at no cost by most Medicare, Medicaid, and Private insurance plans. Please select your payment type below so that we can properly bill your vaccination:*

Please Bill My Medicare InsurancePlease Bill My Private or State Medicaid Insurance PlanI don't have insurance and will pay Cash for my vaccination

Medicare Part B ID Number

If no insurance please provide your Social Security Number