Immunization Appointment Scheduler

Consent to Vaccination

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Sniteman Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Rows	Yes	No	Unsure
Is the person being vaccinated sick today?
Does the person being vaccinated have an allergy to a component of the vaccine?
Has the person being vaccinated ever had a serious reaction to influenza vaccine in the past?
Has the person being vaccinated ever had Guillain-Barre Syndrome?

Rows	Yes	No	Unsure
Are you sick today?
Do you have allergies to medications, food, a vaccine component, or latex?
Have you ever had a serious reaction after receiving a vaccination?
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments?
Have you had a seizure or a brain or other nervous system problem?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
Have you received any vaccinations in the past 4 weeks?
Are you an adult age 50 or older who hasn't received a shingles vaccine?
Is this your second dose of the Shingrix?

Rows	Yes	No	Unsure or N/A
Are you sick today?
Do you have allergies to medications, food, a vaccine component (e.g. diptheria toxoid-containing vaccine), or latex?
Have you ever had a serious reaction after receiving a vaccination?
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments?
Have you had a seizure or a brain or other nervous system problem?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
For women: are you pregnant or is there a chance you could become pregnant during the next month?
Have you had any other vaccinations in the past 4 weeks?

Immunization Appointment Scheduler

Insurance Card Information

Vaccine Information Statements (VIS)

Consent to Vaccination