Vaccine Consent form
Kusler's Compounding Pharmacy - 700 Avenue D. Ste 102 Snohomish WA 98290
Please complete consent form for person to receive vaccine(s)
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health and Medical History
Primary Care Physician:
Do you have any chronic health conditions? ("NA" if none)
*
Please indicate all health issues that are considered within the risk group
Please list any Allergies ("NA" if none)
*
Egg Allergy?
*
Yes
No
Guillain Barre Syndrome?
*
Yes
No
Please include a picture of the front of your insurance card - (or bring to your appointment)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please include a picture of the back of your insurance card - (or bring to your appointment)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Comments:
I hereby declare that all the given information are accurate.
*
Yes
"“I have read or have had explained to me the information in the CDC Vaccine Information Statement(s). I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of this/these vaccine(s) and ask that the vaccine(s) be given to me"
*
Please verify that you are human
*
Submit
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