Vaccine Administration Consent Form
Last Name
*
Required
First Name
*
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Middle Name
Address
*
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City
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State
*
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Select State
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Zip
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Phone
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Mobile
DOB(MM/dd/yyyy)
*
Gender
*
Required
Select Gender
Male
Female
Race/Ethnicity
Select Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiin/Other Pacific Islander
White
Other
Prefer not to say
Seasonal Influenza
Please select desired vaccines
Seasonal Influenza
COVID-19
Hepatitis A
Hepatitis B
Chickenpox (varicella)
HPV
Pneumococcal
Tetanus/TDap
Shingles (zoster)
Meningococcal
MMR
Other
Email
*
Required
Schedule Date
*
Time (Mon - Fri 9 AM - 5 PM EST)
*
Insurance information and authorization:
Insurance Provider Name
CardID
BIN
PCN
Medicare Card (MBI)(Red, Blue & White Card)
Uninsured (SSN)
Remarks / Notes for Pharmacy
Check only if applicable (The following questions will help us determine your eligibility for vaccination today.)
1.
Are you pregnant?
2.
Are you currently breastfeeding?
3.
Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any vaccine or injectable therapy, or a history of anaphylaxis due to any cause?
4.
Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any component of a COVID-19 vaccine, including lipid nanoparticles or polyethylene glycol (PEG)?
5.
Have you received any other vaccine within the past 14 days or are scheduled to receive any vaccine in the next 14 days?
6.
Have you received convalescent plasma or monoclonal/polyclonal antibody infusions for COVID-19 within the past 90 days?
7.
Are you under age 16?
8.
Are you currently sick? For example, are you currently experiencing fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, etc.?
9.
Do you have a bleeding disorder or are you taking a blood thinner?
10.
Have you tested positive for COVID-19 in the last 10 days?
11.
Are you currently in quarantine for COVID-19 exposure?
12.
Do you have any health conditions such as heart disease, diabetes or asthma?
13.
Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré Syndrome (a condition that causes paralysis) or other nervous system problem?
14.
Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS or transplant)?
15.
Have you received any vaccinations or skin tests in the past four weeks?
16.
Are you currently on home infusions, weekly injections such as Humira™ (adalimumab), Remicade™ (infliximab) or Enbrel™ (etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?
17.
Are you currently taking high-dose steroid therapy (prednisone > 20 mg/day or equivalent) for longer than two weeks?
18.
Have you received a transfusion of blood, blood products or been given a medication called immune (gamma) globulin in the past year?
19.
Are you currently taking any antibiotics, antiviral or antimalarial medications? (Typhoid only)
20.
Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)
21.
Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only)
22.
Do you have a nasal condition serious enough to make breathing difficult (e.g., very stuffy nose)?
23.
Have you ever received a dose of COVID-19 vaccine?
If yes, which product?
Select product
Pfizer
Moderna
Janssen (Johson & Johnson)
Hispanic/Latino
Another product
If yes, when was the date of your first dose?
Vaccine
MFR
Date admin.
Vaccine lot No.
Exp. date
Dosage
Injection site
VIS/EUA date
Dose in series
COVID-19
Influenza
Other
Consent for Vaccination
I have reviewed my answers to the questions above with the vaccinator. If I experience any adverse reactions after leaving, I will notify my primary care provider. I have viewed the Emergency Use Authorization Fact Sheet provided to me today. I understand the benefits and risks of the vaccine. The vaccine checked above should be given to the person named above for whom I am authorized to make this request. I understand that I can review a Notice of Privacy Practice at the time of vaccination.
Signature/Name of Parent/Guardian/Patient/Immunizer name
*
Required
Date :
*
Pharmacy Name
CURLEW PHARMACY
Pharmacy Address
30226 US HWY 19 N, CLEARWATER, FL - 33761
Pharmacy Phone
(727) 773-1600
Pharmacy Fax
(727) 773-1700
