Influenza Vaccine Consent Form
Vaccine Recipient Name
Vaccine Recipient Physical Address
Date of Birth
Gender at birth
Vaccine Recipient Phone Number
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
INFLUENZA Vaccine Screening Questions
1. Are you allergic to eggs or egg products?
2. Are you feeling sick today?
3. Have you ever received a dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to any flu shot?
5. Have you received any vaccine in the last 14 days?
6. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
7. Are you pregnant or breastfeeding?
Which arm would you like to get the injection on
Consent (check each box below after reading and prior to signing the form)
Check each box
I am taking this vaccine voluntarily and consent to the vaccination being given to me. I understand the risks and benefits of this vaccine.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand allergic reaction can occur within 4 hours that causes hives, swelling, or respiratory distress, including wheezing.
I hereby waive any claim for damages that I (or anyone claiming on my behalf) may have against Towne Pharmacy, its owner, its employees and agents on account of any injury or misfortune I may suffer as a result of this vaccination.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan. I will be paying out of pocket for the vaccine.
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):
First and Last Name
First and Last Name
Regular flu vaccine
High dose flu vaccine (recommended for patients>65)
Submit Consent Form (required)
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