General Vaccination Consent Form

White Oak Pharmacy General Vaccination Consent Form
Patient Full Name*
First Name and Last Name
Date of Birth*

MonthDayYear
Date
Medicare Claim Number:
1. Is the person to be vaccinated sick today?*

YesNo
2. Does the person to be vaccinated have any allergies to medications, food, a vaccine component, or latex?*

YesNo
3. Has the person to be vaccinated ever had a serious reaction after receiving a vaccination in the past?*

YesNo
4. Does the person have any long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?*

YesNo
5. Does the person have cancer, leukemia, AIDS, or any other immune system problem?*

YesNo
6. Does the person take cortisone, prednisone, other steroids, or anti-cancer drugs, or have you had radiation treatments?*

YesNo
7. Has the person had a seizure or a brain or other nervous system problem?*

YesNo
8. During the past year, has the person received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

YesNo
9. For women: Is the person pregnant or is there a chance she could become pregnant during the next month?

YesNo
10. Has the person received any vaccinations in the past 4 weeks?*

YesNo
Patient Signature *

Clear
Date*

MonthDayYear
Date
Take A Picture of Photo ID
Take A Picture of Insurance Card (Front Side)
Take A Picture of Insurance Card (Back Side)
To be completed by Pharmacist
Vaccine
Manufacturer & Lot Number
Administration Site

Left ArmRight Arm
Dosage

0.5ml2.5mlLAIV
Pharmacist’s Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

To be completed by Pharmacist