Vaccine Consent

If prompted by your care provider, please complete and submit the following consent form prior to receiving your vaccination.

  • Required to add vaccine history to Washington State Immunization Information System (WAIIS)
  • Please take photos of the front and back of your insurance card and attach them here:
    I am at risk of exposure to monkeypox (sexual contact, multiple partners, significant skin-to-skin contact, meth use in the last 1 month, and/or syphilis or gonorrhea in the last year)
  • You may need to receive the vaccine from your physician if you answer YES to any the following:

  • Patient Signature

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


Kelley-Ross is an independently owned corporation operating 4 pharmacies in Seattle. Kelley-Ross provides a wide range of pharmacy services, including prescription dispensing, compounding, medi-set packaging, compliance packaging, long-term care facility services, consultant pharmacist services, immunizations and a variety of health screenings.

We provide Clinical Community Care. This means that our staff combines expert medication therapy management and clinical skills, with caring, patient centered pharmacy services. By using the triad approach – patient, provider and pharmacist – we can help patients maximize their healthcare resources while achieving optimal health outcomes.

Our high service level and commitment to problem solving has made Kelley-Ross the pharmacy of choice for patients and providers across the Northwest.