To be completed by Pharmacist
White Oak Pharmacy General Vaccination Consent Form
Patient Full Name
*
First Name and Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Information
Do we already have your current insurance on file?
*
Yes, I'm an existing White Oak patient and my insurance has not changed
No, I'm a new patient or my insurance has changed
Insurance Company
*
Member ID
*
PCN or RX PCN
Group or RX Group
Do you have Medicare Part B?
*
Yes, and White Oak already has my Medicare Part B number on file
Yes, and this is new or my Medicare Part B number has changed
No
Medicare Part B Number
Please bring your insurance card(s) and a photo ID with you so we can verify your coverage at your visit.
Which vaccine(s) would you like to receive today? (check all that apply)
*
Influenza (Flu) - standard dose
Influenza (Flu) - high dose (65+)
COVID-19
RSV
Shingles (Shingrix)
Pneumococcal (Prevnar 20 / Pneumovax 23)
Tdap (Tetanus, Diphtheria, Pertussis)
Other
You may request more than one vaccine for today's visit. The CDC allows most vaccines to be given at the same visit. Your pharmacist will review your health screening, vaccination history, and insurance coverage, and will decide which vaccines are appropriate to give today.
If Other, please specify (e.g., Hepatitis A or B, HPV, MMR, Varicella, Meningococcal, Td)
Medicare Claim Number:
1. Is the person to be vaccinated sick today?
*
Yes
No
2. Does the person to be vaccinated have any allergies to medications, food, a vaccine component, or latex?
*
Yes
No
3. Has the person to be vaccinated ever had a serious reaction after receiving a vaccination in the past?
*
Yes
No
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?
*
Yes
No
5. Does the person have cancer, leukemia, AIDS, or any other immune system problem?
*
Yes
No
6. Does the person take cortisone, prednisone, other steroids, or anti-cancer drugs, or have you had radiation treatments?
*
Yes
No
7. Has the person had a seizure or a brain or other nervous system problem?
*
Yes
No
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?
*
Yes
No
9. For women: Is the person pregnant or is there a chance she could become pregnant during the next month?
Yes
No
10. Has the person received any vaccinations in the past 4 weeks?
*
Yes
No
Patient Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Take A Picture of Photo ID
Take A Picture of Insurance Card (Front Side)
Take A Picture of Insurance Card (Back Side)
By providing your phone number and checking this box, you agree to receive recurring text messages from White Oak Rx. Message frequency may vary. Message and data rates may apply. Reply HELP for help, STOP to cancel.
I accept
Privacy Policy
|
Terms & Conditions
Vaccine
Manufacturer & Lot Number
Administration Site
Left Arm
Right Arm
Dosage
0.5ml
2.5ml
LAIV
Pharmacist’s Signature
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: