Lopez Island Pharmacy (360) 468-2616 Fax (360) 468-3825
Vaccination Consent Form
rev:06/04/2020 HIPAA Compliant ver 1.3
Influenza Vaccine is NOT available until the Fall of 2020
**** PLEASE MAKE ANOTHER SELECTION ****
For Patients:The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.
It is important for you to have a personal record of your vaccinations. If you don’t have a personal record,ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every time you seek medical care. Make sure your healthcare provider records all your vaccinations on it.
All our vaccinations are logged on the Washington Immunization System and can be accessed by most health care providers should they need to see your records