Immunization Consent Form
Please have your pharmacy insurance card ready when completing
Which Vaccine are you looking for?
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Seasonal Flu (Quadrivalent)
Seasonal Flu (Ages 65+)
Shingles (Shingrix - Ages 50+)
Tetanus/Pertussis (Tdap/Whooping Cough)
Pneumonia (Prevnar 20 or Pneumovax 23 - Ages 65+)
RSV
Appointment
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Tetanus, Diphtheria, and Pertussis (Tdap)
Please provide reason for vaccination:
Routine
Injury
Pregnancy
Other
Shingles Vaccine
Shingrix is a two dose series recommended for those 50 years and older.
Which Shingles Dose are you looking for?
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First
Second
When was your first dose of Shingrix?
Please enter date of first dose. Recommended spacing between doses is two to six months.
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.
Do you have any of the following underlying medical conditions associated with increased risk for severe RSV disease? (Select all that apply)
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Chronic Lung Disease (COPD, Asthma)
Chronic Kidney Disease
Chronic Cardiovascular Disease (CHF and CAD)
Chronic Liver Disease
Moderate or Severe Immunocompromise
Chronic Hematologic Disorders
Diabetes Mellitus
Chronic or Progressive Neurologic or Neuromuscular Conditions
None
Any Underlying Condition that a Provider determines might increase the risk of severe RSV Disease
Are there other factors associated with increased risk for severe RSV disease that apply?
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Frailty or Advanced Age
Residence in a nursing home or other long-term care facility
Any underlying factor a provider determines might increase the risk of severe RSV Disease
None
Are there any other factors you'd like the pharmacist to know? If pregnant, please indicate your gestation week and due date.
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Billing Information
Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
How should we bill for this vaccine?
*
My insurance is already on file. (Existing Patient)
Pay out of Pocket
Prescription Insurance
Medicare Part D/ Medicare Advantage
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Prescription Insurance Card Information
Please provide the following information from your prescription insurance card and/or upload an image of your card.
BIN
PCN
Rx Group
Identification Number
Upload Image of Card (Front and Back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide your Medicare Part B ID Number (not Social Security Number)
ID Number is located on the paper red, white, and blue Medicare card and should be a series of number and letters separated by dashes. See Example Below.
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Patient Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
We only immunize 5 years old and older
Gender
*
Female
Male
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Patient Phone Number
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Mother's Maiden Name
*
Utilized for the statewide immunization registry
Primary Care Provider (PCP) Name
First Name
Last Name
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.
Are you sick today?
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Yes
No
Do you have any allergies to medications, food, eggs, yeast, latex, or a vaccine component?
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Yes
No
Have you ever had a serious reaction after receiving a vaccination?
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Yes
No
Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
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Yes
No
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?
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Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?
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Yes
No
In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
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Yes
No
Have you had a seizure, brain/other nervous system problem or Guillain Barre?
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Yes
No
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug (including acyclovir, famciclovir, valacyclovir)?
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Yes
No
Have you received any vaccinations or TB skin test in the past 4 weeks?
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Yes
No
Do you have a history of fainting, particularly with vaccines?
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Yes
No
For women: Are you pregnant or is there a chance you could come become pregnant during the next month?
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Yes
No
N/A
For Tdap and adult Td: Do you have a cut, injury, puncture or open would that prompted you to get a tetanus shot?
*
Yes
No
N/A
For Shingles (Zoster) vaccine: Have you had a past reaction to gelatin or triple antibiotic ointment?
*
Yes
No
N/A
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.
Form completed by
*
First Name
Last Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)
Pharmacy Use Only
Do no complete the below questions
Signature/Title of Immunization Administrator
Signature of Pharmacist
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