Immunization Screening Consent

Immunization Screening & Consent Form
Immunization Site:
What is your requested appointment date and time (Complete if you selected In store option)?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
Immunization Screening & Consent Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Current Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age - days
Age
Gender
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Ethnicity
Race
Address

Home Address

Street Address Line 2

CityState

Zip
Mother's Maiden Name

First NameLast Name
I want to receive the following immunization(s):
Preferred Arm
COVID-19 series
COVID-19 immunization company

Please answer the following questions to help us decide if you can get a vaccination today:

Rows	YES	NO
Are you currently sick with a moderate to high fever, vomiting/diarrhea?
Have you ever fainted or felt dizzy when receiving an immunization?
Have you ever had a serious reaction after receiving an immunization?
Do you have allergies to medications, food, or vaccines? (examples: eggs, bovine protein, gelatin, gentamycin, polymyxin, neomycin, phenol, yeast, or thimerosal) If yes, please list below:
Have you ever had a seizure disorder for which you are on seizure medications(s), a brain disorder, Guillain-Barre syndrome, or other nervous system problem?
Are you 50 years of age or older?
Do you smoke, use e-cigarettes, or vape?
Have you ever had a pneumonia vaccination?
Questions? Do you have any questions you would like to ask the pharmacist?
Do you have a chronic condition or long-term health problem? If yes, please check all that apply below:

Chronic condition or long-term health problem

Other
Allergies:
If you do not have any, type NONE.
- I give permission to the Providence Community Pharmacy pharmacist, Certified Pharmacy Tech or the intern to give me the vaccines(s) I have check marked.
- I understand the risks and benefits associated with the vaccines(s) I am getting. I have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I am getting. I have had a chance to ask questions and I understand the answers.
- I understand that it is not possible to predict all the possible side effects or complications associated with the vaccine(s) I am getting.
- I give permission for Providence Community Pharmacy to give information to Medicare, Medicaid, or any other insurance I have to help pay my bill. I allow Medicare, Medicaid and any other insurance I have to pay Providence Community Pharmacy. I know that I will have to pay any bills that Medicare, Medicaid or my other insurances do not pay.
- I accept responsibility for seeking medical attention for any problems with this vaccination.
I have discussed the Covid-19 vaccine with the pharmacist and choose to receive it today.
Should be Empty:

Immunization Screening & Consent Form