Grants Pass Pharmacy
Vaccine Appointment and Consent Form
Name
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First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race
Gender per insurance
Mother's maiden name
Phone Number
*
Please enter a valid phone number.
Emergency Contact
Emergency contact phone number
Please enter a valid phone number.
Which vaccine(s) are you requesting?
*
Flu
Hepatitis A
Hepatitis B
Pneumonia
Shingles
Tetanus/Tdap
Other
Please list any allergies you have (medication, food, vaccine component, latex)
*
Desired appointment time
*
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Vaccine Screening Questions
These questions will help us determine which vaccines you may be given today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It means you may be questioned further for safety.
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Yes
No
Don't Know
Are you sick today?
Have you ever had a serious reaction after receiving a vaccination?
COVID-19: History of myocarditis/pericarditis or diagnosis of multisystem inflammatory syndrome?
Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak?
Are you on long-term aspirin therapy or other blood thinners?
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
In the past 3 months, have you taken medications that affect your immune system? (corticosteroids, anticancer drugs, drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis) Or have you had radiation treatment(s)?
Have you had a seizure or brain or other nervous system problem?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
Are you pregnant or is there a chance you could become pregnant during the next month?
Have you received any vaccinations in the past 4 weeks?
Do you work in healthcare?
Are you regularly exposed to blood or bodily fluids?
Do you currently smoke?
Have you received hematopoietic cell transplant or CAR-T cell therapy?
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Insurance Information
This information will help us process your vaccine. If the information here is incomplete or incorrect it may delay your appointment time.
Insurance card FRONT
Insurance card BACK
Insurance name
Insurance ID number
*
65+ Medicare number (Red, White, and Blue card)
Rx BIN
Rx PCN
Rx GRP
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Signature
I hereby give my consent to the health care provider of Grants Pass Pharmacy to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read and/or had explained to me the CDC’s Vaccine Information Statement (VIS) or the FDA’s Emergency Use Authorization (EUA) on the vaccine(s) I have elected to receive. I have had the opportunity to ask questions that were answered to my satisfaction. As with all medical treatment, there is no guarantee that I will not experience an adverse reaction from the vaccine. I understand that the information contained on this form may be shared with the Stated Health Division (SHD) and/or state immunization registries and will remain confidential and will not be released except as permitted or required by law. If eligible, I authorize Grants Pass Pharmacy to submit a claim for reimbursement on my behalf to Medicare or any other contracted third party payor. If the claim is denied, I understand that I will be responsible for payment. I understand if my claim to the HRSA Uninsured Funding is not reimbursed because it is determined that I have third-party insurance, I authorize Grants Pass Pharmacy to utilize my protected health information and other identifiers to try to identify and bill my insurance. I acknowledge that I have received a copy of the Notice of Privacy Practices. Furthermore, I agree to remain near the vaccination location for approximately 15-30 minutes after administration for observation by the administering healthcare provider.
Electronic signature
Your typed name expresses consent to the above statement.
Date signed
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Month
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Day
Year
Date
Submit
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