RSV & Shingles Vaccine Consent Form
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. VIS link https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.pdf
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Vaccine Recipient Name
Vaccine Recipient Physical Address
Date of Birth
Gender at birth
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Vaccine Recipient Phone Number
Primary Care Provider Name
Vaccine Screening Questions
1. Are you feeling sick today?
2. Have you ever had a serious reaction after receiving a vaccine?
3a. Do you have allergies to medications, food, a vaccine ingredients or latex?
3b. Have you ever had an allergic reaction to
3c. Have you ever had an allergic reaction to a previous dose of Pneumonia or Shingles Vaccine?
4. Have you ever had an allergic reaction to an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of a vaccine, polysorbate, or any vaccine or injectable medication?
This would include food, pet, environmental, or oral medication allergies.
6. Do you have a parent, brother or sister with an immune system problem?
7. Have you had a seizure or a brain or other nervous system problem?
8. Do you have a long-term health problem with heart, lung, kidney?
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs,steroids or therapies?
10. During the past year, have you received a tansfusion of blood or blood products or been given immune globulin or an antiviral drug?
11. Have you received any vaccinations in the past 4 weeks?
Which arm would you like to get the injection on?
Please select vaccine
Shingles & RSV
Consent (check each box below after reading and prior to signing the form)
Check each box
I understand the benefits and risks of the Pneumonia vaccine as described in the Fact Sheet a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I agree that vaccination and administration fee will be billed to my insurance.
Please Upload Insurance Card
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Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
First and Last Name
First and Last Name
Submit Consent Form (required)
Should be Empty: