Carillon Point Flu and Covid Vaccine Consent

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Personal Information

Chosen Name*

First Last

Birth Date*

MM slash DD slash YYYY

Gender*

Home Phone*

Email*

Address*

Street Address Line 1 Street Address Line 2 City State ZIP Code

Race*

Race is required by the state's immunization registry

Ethnicity*

Ethnicity is required by the state's immunization registry

Health Insurance

Please take photos of the front & back of your insurance card, and Medicare Card if you are over 65. Attach the images here (Click in each field below to upload your images):

Front

Back

Medicare

General Health Screening Questions

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. It just means additional questions must be asked. If a question is not clear, please ask your health care provided to explain it.

1. Are you feeling sick today?*

Yes

Unsure

2. Have you ever had an allergic reaction to medications, food, latex or a previous vaccine component?*

Yes

Unsure

3. Have you ever had a serious reaction after receiving a vaccine?*

Yes

Unsure

4. Do you have any of the following: a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?*

Yes

Unsure

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*

Yes

Unsure

6. Do you have a parent, brother, or sister or someone you are living with who has an immune system problem?*

Yes

Unsure

7. In the past 6 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?*

Yes

Unsure

8. Have you had a seizure or a brain or other nervous system problem such as Guillain-Barre?*

Yes

Unsure

9. Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?*

Yes

Unsure

10. In the past year, have you received immune (gamma) globulin, blood/blood products, or an antiviral drug?*

Yes

Unsure

11. Are you pregnant?*

Yes

Unsure

12. Have you received any vaccinations in the past 4 weeks?*

Yes

Unsure

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Today’s Date

MM slash DD slash YYYY

Consent, Authorization & Signature

By signing below, I certify the following:

Consent for services: I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

Authorization to request payment: I do hereby authorize Kelley-Ross Pharmacy (KR) to release information and request payment. I certify that the information given by me in applying for payment under my insurance is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

Disclosure of records: I understand that KR may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at KR (if applicable), my primary care physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other healthcare operations (such as administration or quality assurance). I also understand that KR will use and disclose my health information as set forth in the KR notice of privacy practices (copy is available in store, online, or by requesting a paper copy from the pharmacy). If I am receiving a vaccine through clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator. I have answered the above questions knowing they represent risks to receiving vaccines. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccines cited and ask that the vaccine(s) below to be given to me or to the person named above (for whom I am authorized to make this request.) I understand that it is recommended that I stay on the premises for 15 minutes after the vaccine is given in case of complications.

I hereby certify that I have received and/or read the pharmacy’s notice describing how medical information about me may be used and disclosed, and how I can gain access to this information.

I hereby certify that I have received and/or read the pharmacy’s notice describing how medical information about the patient I am signing for may be used and disclosed, and how I can gain access to this information.

Signature*

Use your mouse, finger, or stylus to sign in the space provided below.

Guardian Signature*

Guardian, please use your mouse, finger, or stylus to sign in the space provided below.

Next of Kin/Guardian Name*

First Last

Next of Kin/Guardian Relationship*

Next of Kin/Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Next of Kin/Guardian Phone*

Today's Date*

MM slash DD slash YYYY

Next of Kin Name*

First Last

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