General Vaccine Consent Form

Select Date & Time*

I want to receive the following vaccines (check all that apply)*

Are you a new or returning patient for Mannino's Family Practice Pharmacy?*

New PatientReturning Patient

Name*

First NameMiddle InitialLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone*

10-digit US phone number

Date of Birth*

MonthDayYear

Date of Birth Single-Line

Date

Age*

Gender*

Social Security Number:*

Email*

example@example.com

Race*

Other Race*

Mother's Maiden Name*

Primary Doctor*

Would you like to upload your a picture of your insurance card or type out the information?*

Upload Insurance Card Picture(s)Type Insurance Information

Upload Insurance Card Picture(s)*

Front and back of card

Insurance Carrier*

Cardholder ID*

RxBIN*

Rx PCN*

Rx Group*

Are you sick today?*

YesNo

Do you have allergies to medications, foods, latex, or a vaccine components?*

YesNo

If yes, please list what you are allergic to:*

Have you ever had a serious reaction after receiving a vaccination?*

YesNo

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?*

YesNo

If yes, please list your long-term health problem(s):*

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*

YesNo

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?*

YesNo

Have you had a seizure, Guillain-Barre Syndrome, a brain or other nervous system problem?*

YesNo

During the past year have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

YesNo

Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNo

Have you received any vaccinations in the past 4 weeks?*

YesNo

Have you previously received a dose of the vaccine(s) you are receiving today?*

YesNo

If yes, please list the date you received a dose of the vaccine(s):*

Influenza Vaccine Information Sheet:

Prevnar 20 Vaccine Information Sheet:

Shingrix Vaccine Information Sheet:

Tdap Vaccine Information Sheet:

COVID Vaccine Information Sheet:

Appointment Date for Reminder

Date

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*

Signature of patient or legal guardian, if patient under age 18.

Signature Date

Date

Vaccine Appointment & Consent Form

Schedule Your Appointment

Patient Information

Patient Questions

Vaccine Information

Consent and Waiver