Vaccine Consent Form
Fill out this form online and print it to bring to your appointment, or complete it at the pharmacy.
Consent and Release — Injectable Vaccinations
Patient Information
Consent and Release
I acknowledge that I understand the benefits and risks of the requested vaccination as described in the Vaccine Information Sheet, a copy of which is provided with this Consent and Release. I confirm that Louis Morgan #4 has answered to my satisfaction all my questions about the vaccine, and the vaccination procedure. I request and consent the vaccination to be given, as I directed Louis Morgan #4, either to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.
I understand that I am giving Louis Morgan #4 permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company or immunization registry, as applicable, to enable Louis Morgan #4 to process my insurance claims with respect to the vaccination.
I, for myself (and for the recipient of the vaccination, if the recipient is a minor), my heirs, executors, and assigns hereby release Louis Morgan #4 from any and all claims arising out of or in connection with the quality of the below described vaccine(s) as provided by the manufacturer and any negligence of Louis Morgan #4 in connection with the related injection of the vaccination. I understand that the laws of my state may affect my remedies in connection with this vaccination. I understand that if my insurance does not pay for this vaccine, I will be personally responsible for any amount due to Louis Morgan #4.
Screening Questions
Please answer each question. If a question is not clear, please ask the pharmacist.
| Question | Yes | No |
|---|---|---|
| Have you ever received a SHINGLES vaccine? | ||
| Are you sick today? | ||
|
Do you have a serious allergy to ANY medications or food?
(Example: Eggs, Gelatin, Thimerosal, Neomycin, Gentamicin, etc.) |
||
| Have you ever had a serious reaction or fainted after receiving any vaccination? | ||
| Do you have sensitivity to latex? (Example: Gloves, Bandages, etc.) | ||
| Women: Are you pregnant or are you considering becoming pregnant? | ||
|
Have you received any vaccination in the past 4 weeks?
|
||
| Do you have cancer, leukemia, HIV, shingles, or any other immune system problem? | ||
| Do you take prednisone, oral steroids, anticancer drugs, antiviral medications or medications that affect the immune system? | ||
| During the past year, have you received a transfusion of blood or blood products, been given a medicine called immune (gamma) globulin or had radiation therapy? |
Patient Signature
Vaccine Administration (Pharmacy Use Only)
| Vaccine | Manufacturer | Lot # | Exp. Date | Dosage / ROA | Site | Time |
|---|---|---|---|---|---|---|
| Flu | 0.5 ml / IM | |||||
| Prevnar 20 | Pfizer | 0.5 ml / IM | ||||
| Shingrix | Glaxo | 0.5 ml / IM | ||||
| Adacel | Sanofi | 0.5 ml / IM | ||||
| SpikeVax | Moderna | 0.5 ml / IM | ||||
Pharmacist Signature (Pharmacy Use Only)
Once you've filled out the form, print it and bring it to the pharmacy for your vaccination appointment.