Date of Birth
Vaccine(s) to receive?
Tetanus/Pertussis (Tdap - whooping cough)
Pneumonia (Prevnar or Pneumovax)
Primary Care Provider (PCP) Name
PCP Phone Number
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.
Form completed by?
Consent to Vaccination
I hereby claim that the above information is true and correct to the best of my knowledge. I consent that pharmacists affiliated with [XXX] Pharmacy may administer this vaccine. I have been informed of the risks and benefits of the vaccine via the CDC-issued Vaccine Information Statement (VIS). I give permission to [XXX] Pharmacy to seek compensation through my insurance, if applicable, knowing that my insurance may not fully cover the associated costs of the vaccine and administration. If this occurs, I understand that I am fully responsible for all costs associated with the administration of the vaccine. I also give consent to have this vaccine information shared as necessary with appropriate parties, including my healthcare provider and the immunization registry, [State] Statewide Immunization Information System.
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