Vaccine Consent Form
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. VIS link https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.pdf
Select an appointment time
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Vaccine Recipient Name
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First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
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Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
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/
Month
/
Day
Year
Gender at birth
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Please Select
Male
Female
Race
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Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
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Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
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Primary Care Provider Name
Email
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example@example.com
Vaccine Screening Questions
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Yes
No
1. Are you feeling sick today?
2. Have you ever had a serious reaction after receiving a vaccine?
3a. Do you have allergies to medications, food, a vaccine ingredients or latex?
3b. Have you ever had an allergic reaction to
Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of Pneumonia or Shingles Vaccine?
4. Have you ever had an allergic reaction to an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of a vaccine, polysorbate, or any vaccine or injectable medication?
This would include food, pet, environmental, or oral medication allergies.
6. Do you have a parent, brother or sister with an immune system problem?
7. Have you had a seizure or a brain or other nervous system problem?
8. Do you have a long-term health problem with heart, lung, kidney?
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs,steroids or therapies?
10. During the past year, have you received a tansfusion of blood or blood products or been given immune globulin or an antiviral drug?
11. Have you received any vaccinations in the past 4 weeks?
Which arm would you like to get the injection on?
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Left Arm
Right Arm
Please select vaccine
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Shingles
RSV
Pneumonia
Yellow Fever
Tetanus
Consent (check each box below after reading and prior to signing the form)
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Check each box
I understand the benefits and risks of the Pneumonia vaccine as described in the Fact Sheet a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I agree that vaccination and administration fee will be billed to my insurance.
Please Upload Insurance Card
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Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed
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Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Vaccine Manufacturer
Prevnar 20
Pharmacy Name
Pharmacy NPI
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Submit Consent Form (required)
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