Clone of Immunization Consent Form Logo

  • Immunization Consent Form

    Please have your pharmacy insurance card ready when completing

  • One of the selected vaccines is currently unavailable. 

     Please check back at a later date for updates.

    Thank you!

  • Tetanus, Diphtheria, and Pertussis (Tdap)

  • Shingles Vaccine

    Shingrix is a two dose series recommended for those 50 years and older.

  • RSV Vaccination for Adults 60 Years and Older and between weeks 32 and 36 of Pregnancy

  • Please note that appointments for RSV Vaccinations are requests only. Pharmacy staff will reach out to approve requests based on eligibility for vaccination.

    • Respiratory syncytial virus (RSV) is a cause of severe respiratory illness across the lifespan. Each year in the United States, RSV leads to approximately 60,000-160,000 hospitalization and 6,0000-10,000 deaths among adults 65 years and older.
    • Adults 60 years and older may be eligible for one dose of RSV vaccine based on patient history and recommendation from their health care provider. 
    • Patients who are between 32 and 36 weeks of pregnancy may be eligible for vaccination. 

  • Billing Information

    Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.

  • Prescription Insurance Card Information

    Please provide the following information from your prescription insurance card and/or upload an image of your card.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Image-124
  •  - -

  • For Patients: The following 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 today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.

  • Consent to Vaccination

    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 Duvall Family Drugs, 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 vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
  • Clear

  • Pharmacy Use Only

    Do no complete the below questions
  • Image-85
  • Should be Empty: