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    Rivergate Pharmacy & Componding Center

    575 Rivergate Lane #111 Durango, CO 81301

    www.rivergatepharmacy.com Phone:

    (970)375-7711

  • Immunization Screening Questionnaire and Consent Form

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  • Insurance Information (Please provide a copy of your insurance cards)

  • PAST MEDICAL HISTORY

  • The following questions will help determine which vaccines may be given today. If a question is not clear, please ask for an explanation.

  • If you answered "No" to the previous question, ask the Pharmacist to give you one.

  • Consent for Administration of Vaccine:

    I am aware of the potential risks and side effects of the vaccine as. described in the literature as well as the risk of the disease it prevents. I hereby waive any liability towards pharmacy and/or its administering employee of potential adverse effects associated with administration of the vaccine. I authorize the release of any medical or other information necessary to process the claim and I hereby assign all insurance, Medicare, Medicaid and other third-party payors' benefits for services rendered. I have been offered the HIPAA Privacy Policy.
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  • TO BE COMPLETED BY IMMUNIZER

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