General Vaccine Consent Form - Update

  • Vaccine Appointment & Consent Form

  • Schedule Your Appointment

  • Select Date & Time*

  • Patient Information

  • I want to receive the following vaccines (check all that apply)*
  • Are you a new or returning patient for Mannino's Family Practice Pharmacy?*
  • Format: (000) 000-0000.
  • Date of Birth*
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  • Date of Birth Single-Line
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  • Would you like to upload your a picture of your insurance card or type out the information?*
  • Browse Files
    Drag and drop files here
    Choose a file
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  • Patient Questions

    Please answer the following questions so we can assess the safety and appropriateness of vaccination:
  • Are you sick today?*
  • Do you have allergies to medications, foods, latex, or a vaccine components?*
  • Have you ever had a serious reaction after receiving a vaccination?*
  • Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia or other blood disorder?*
  • Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
  • In the past 3 months, have you taken medication that weakens your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*
  • Have you had a seizure, Guillain-Barre Syndrome, a brain or other nervous system problem?*
  • During the past year have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*
  • Are you pregnant or is there a chance you could become pregnant during the next month?*
  • Have you received any vaccinations in the past 4 weeks?*
  • Have you previously received a dose of the vaccine(s) you are receiving today?*

  • Vaccine Information

    Please review the vaccine information sheet(s) below.
  • Appointment Date for Reminder
     - -

  • Consent and Waiver

  • I, Authorize the pharmacy staff of Mannino’s Family Practice Pharmacy to administer the selected Vaccine(s) to myself/my child or minor of which I am guardian (as applicable). I have been provided the Vaccine Information Statement and understand the benefits and risks of receiving this vaccine. I understand the possible side effects. I have had the opportunity to ask questions of the pharmacist. I understand that notification of this vaccine administration will be sent to the primary care physician listed above and to the Louisiana Immunization Network for Kids Statewide (LINKS). I have also been given a copy of Mannino’s Pharmacy HIPAA policy. I also authorize Mannino’s Pharmacy to bill Medicare, Medicaid or any other applicable third party on my behalf. In addition, I understand that I am responsible for any deductible or coinsurance not paid by the third party and agree to pay the unpaid amount. I agree to wait near the vaccination area for approximately 20 minutes to be monitored/receive treatment in case of adverse reaction

  • Signature Date
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  • Should be Empty: