Pneumovax 23 Consent Form

Pneumovax 23 Consent Form

Pneumococcal Vaccine 23 Polyvalent
First
MI
Last
DOB:
Gender

MF
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Home Phone:
Cell Phone:
SS#:
Email address:
example@example.com
Race:

WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeHispanic, Latino, or SpanishNative Hawaiian or Pacific Islander
Primary Physician:
Past Medical History
Have you ever had an allergic reaction after a previous dose of pneumococcal vaccine or diphtheria toxoid containing vaccine?

YesNo
What was the date of your last dose of pneumococcal vaccine?

MonthDayYear
Date
Do you have a moderate of severe infection today (with greater than 101.3 degrees or without a fever)?

YesNo
Do you take immunosuppressive therapies including irradiation, antimetabolites, alkylating agents, anti-TNF, cytotoxic drugs, or are you HIV infected, a transplant recipient, have an autoimmune disorder, have had a splenectomy, or taking steroids (>20mg/day) for more than 2 weeks or a recent immunization?

YesNo
Consent to Immunize
I reviewed a copy of the Vaccine Information Statement (VIS) and have had the opportunity to ask questions about the risks and benefits of this vaccination.

YesNo
Vaccine Information Statement
I understand common side effects may include aches, headache, fatigue, fever, chills, decreased appetite, and injection site redness, swelling, or pain and that the benefits include disease prevention.

YesNo
This vaccination record may be reported to the Texas Department of Health Immunization Tracking Service and primary healthcare providers.

YesNo
I consent for the vaccination to be administered to me and for the immunizer to initiate the emergency medical plan if necessary due to a reaction of the vaccination.

YesNo
I am aware of the potential risks and side effects of the vaccine as described in the literature as well as the risk of the disease it prevents. I hereby waive any liability towards Valmed Home Health & Pharmacy Solutions and/or its administering employee of potential adverse effects associated with administration of the vaccine. I authorize the release of any medical or other information necessary to process the claim and I hereby assign all insurance, Medicare, Medicaid and other third-party payors benefits for services rendered. I have been offered the HIPAA Privacy Policy. I understand that third party payors may not cover the vaccination and I agree to pay for services rendered.
Signature

Clear
Date

MonthDayYear
Date
Relationship (If Minor)
Please verify that you are human*
Should be Empty:

Pneumovax 23 Consent Form

Past Medical History

Consent to Immunize