After booking a vaccine appointment with us, please complete and submit the consent form below prior to your visit

Name*
Birth Date*
Gender*
Address*
Is this part of an organized flu shot event?*
Please take photos of the front and back of your insurance card and attach them here:
 

You may need to receive the vaccine from your physician if you answer YES to any the following:

Have you ever had a severe reaction to any vaccine?*
Are you ill today? (Moderate to severe acute illness)*
Do you have allergies to medications, food, or any vaccine?*
Have you had Guillain-Barre Syndrome, a serious auto immune problem?*
Do you have cancer, leukemia, HIV/AIDS or any immune system problems?*
Within the last 3 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?*
During the past year, have you received a transfusion or blood or blood products, or been given a medicine called immune (gamma) globulin?*
For women: are your pregnant or planning pregnancy in the next few months? (Men please select NO)*
Have you received any vaccinations in the past 4 weeks?*
Do you have an allergy to latex (rubber)?*
 

Patient Signature

By signing below, I certify the following:

I have answered the above questions knowing they represent risks to receiving the flu and pneumonia 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.

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

 

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