FLU Vaccine Eligibility and Consent Form

FLU Vaccine Eligibility and Consent Form
Are you interested in receiving a Flu vaccine?*

YesNo
This form is specific to determining if you are eligible for a Flu Vaccine. You have indicated that you are not interested in receiving a Flu vaccine. Please make sure you have selected the correct form. If you have further questions or concerns please contact us at 270-547-2855. Thanks!
What is the age of the person to be vaccinated? (if prompted below please select next)*

6 months to 4 years5 years and up
Based on your selected age, you are not eligible to receive a Flu Vaccine at Save-Rite Drugs in Irvington. Please contact your Pediatrician, Primary Care Provider or Health Department to inquire about a Flu Vaccine for your child. If you have any questions you may contact us at 270-547-2855. Thanks!

FLU Vaccine Eligibility and Consent Form
Select Pharmacy Location to Receive Flu vaccination at:*
Name of Person Receiving Vaccine*

First NameLast Name
Gender*

MaleFemaleOther
Ethnicity (Please select one)*

Non-HispanicHispanic
Date of Birth*

MonthDayYear
Date
Age*
Address*

Address

Street Address Line 2

CityState

Zip
Phone Number*
Medication or Medical Related Allergies (if none please type N/A or None)*
Race*
Who is your Primary Care Provider (PCP)? (Worded differently, who is your Doctor)*
What is your Primary Care Providers (PCP) Phone Number? (Worded differently, what is your Doctors phone number?)
Do you feel sick today?*

YesNo
Do you have an allergy to an ingredient of the Flu Vaccine or an allergy to eggs? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or an EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling or respiratory distress, including wheezing.)*

YesNo
Have you ever had a serious reaction to a previous dose of the Flu Vaccine? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or an EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling or respiratory distress, including wheezing.)*

YesNo
Have you ever received a Flu Vaccine before?*

YesNo
Have you ever had or been diagnosed with Guillain-Barre Syndrome?*

YesNo
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 and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless The Save-Rite Family of Pharmacies (to include Save-Rite Drugs, Inc, Save-Rite Drugs Brandenburg, Save-Rite Drugs Radcliff, Inc and Save-Rite Drugs Hardinsburg, Inc) 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 vaccines. I certify that I am at least 18 years old and hereby give my consent to the pharmacists or Certified Pharmacy Technician of Save-Rite Drugs, Inc., Save-Rite Drugs Brandenburg, Save-Rite Drugs Radcliff and/or Save-Rite Drugs Hardinsburg to administer the vaccine and I also consent that my vaccination may be administered by a nurse that is operating under their authority by the KY Board of Nursing. If a nurse is administering the vaccine they will be receiving the dispensed vaccine from Save-Rite Drugs, Inc, Save-Rite Drugs Brandenburg, Save-Rite Drugs Radcliff and/or Save-Rite Drugs Hardinsburg. If under 18 years old signature by parent or guardian is required.*

Agree
Name of Person Authorizing Vaccine (only complete this if your name is different that the name provided above e.g. a parent or guardian of a minor)

First NameLast Name
Please bring a copy of your prescription insurance card or Medicare Part B (Red, White and Blue card) to your appointment. If you do not have prescription insurance you may pay out of pocket for your Flu Vaccine. A high dose Flu Vaccine (for those ages 65+) will be $75 and a regular dose Flu vaccine (for ages 5-64) will be $40.

After clicking the submit button below, you will be directed to schedule your appointment for your Flu vaccine. If you would also like to receive another vaccine during your same appointment, such as COVID-19 or Pneumonia, you must fill out another eligibility and consent form for your other requested vaccine and you will schedule a 2nd appointment for that vaccine as well.

You will be directed on how to complete another eligibility and consent form for your 2nd vaccine when you finish scheduling your first vaccine.

If you have any questiosn please feel free to contact us at 270-547-2855. Thanks!
Signature*

Clear
Date *

MonthDayYear
Date
This QR Code will take you to the required Vaccine Information Sheet that must be offered with each vaccine given. If you wish to receive a printed copy of this VIS, please inform us when you arrive at the pharmacy. Thanks!
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