Informed Consent for Immunization with Inactivated Vaccine
Which arm do you prefer for vaccine?
Enter weight IF LESS than 66 pounds: Lbs.
(please circle) Left Right
Primary Care Provider Name: _________________________ Vaccine requested: _________________________
Primary Care Provider Address:
___________________________________
reening Questionnaire: Please answer questions by checking the boxes.
Screening Questions – NOTE: IF COMPLETED ONLINE, REVIEW ANSWERS WITH PATIENT TO ENSURE NO CHANGES
2.
Do you have a serious allergy to ANY medications or food (e.g. eggs, gelatin, thimerosal, neomycin, gentamicin, etc.)? If yes,
please list:
_____________________________________________________________________________________________
Have you ever had a serious reaction or fainted after receiving any vaccination?
Do you have sensitivity to latex (e.g. gloves or bandages)?
Do you have a seizure disorder or a brain disorder? (Tdap only)
6.
For women: Are you pregnant or are you considering becoming pregnant in the next month?
7.
Do you have a medical condition or take medication(s) that may weaken your immune system? If yes, please list:
_____________________________________________________________________________________________________
Immunization Needs – NOTE: COVID-19 VACCINE CANNOT BE ADMINISTERED WITH OTHER IMMUNIZATIONS
8.
Please check all that apply to you:
Asthma Diabetes Heart Disease Tobacco Smoker 65 Years or older
If you checked any of the above, have you ever received a PNEUMOCOCCAL vaccine? If yes, when? ____________
Patients 50 and older: Have you ever received the SHINGLES vaccine?
How many years has it been since your last TETANUS vaccine?
11.
Patients 45 and under: Have you received the HPV (Human Papillomavirus) vaccine?
12.
Patients aged 11 to 23: Have you received a meningitis vaccine?
13.
Please indicate which vaccine(s) you would like more information about?
Hepatitis A Hepatitis B MMR (Measles, Mumps, Rubella) Travel Vaccines Other: __________________________
Informed Consent: Please read and sign.
By my signature below, I consent to the administration of the vaccine(s) by a pharmacist or a supervised student pharmacist or technician, where permitted by law or state/federal
guidance
, employed by Albertsons Companies or one of its affiliated pharmacies and to be contacted at the number provided above regar
ding other immunizations for which I am
due or eligible to receive. I also release Albertsons Companies and its subsidiaries, affiliates, officers, directors, employees, and agents from all liability, including acts of omission
or commission, resulting or arising from my receipt of this vaccination. I understand that: 1) I have voluntarily chosen to
receive the vaccination and under
stand that I am obligated
to pay for all products and services received
, if applicable. 2) I may be responsible for payment after the date of service if the product or service is billed to my medical benefit. 3)
I
am of legal age and authorized to execute
this consent form or I am the parent/guardian of the minor patient.
4) I will immediately alert the pharmacist of any medical conditions
which may adversely affect my personal health or effectiveness of the vaccine. 5) I
have been counseled about potential
side effects after vaccination, when they may occur, and
when and where I should seek treatment. I am responsible for following up with my physician at my expense if I experience any
side effects. 6) I should remain in the area for 15
minutes after the va
ccination for observation. 7) I have read, or have had read to me, the Vaccine Information Statement(s) (“VIS”) or Emergency Use Authorization (“EUA”)
provided
for the vaccine(s) to be administered. I have
had the opportunity to ask questions, and all my q
uestions have been answered to my satisfaction. I understand the benefits and risks
of the vaccine(s). 8) I
have been offered and/or provided a copy of the company’s Notice of Privacy Practices in compliance with the Health Insurance Portability and Accoun
This vaccination, including any vaccination granted additional privacy protections under state or federal law, is subject to
reporting by my pharmacy or its business
associate to an immunization registry, which may share my immunization data with others, and to my primary care physician, the authorizing physician, or the local Department of
Health, if applicable, and I authorize these disclosures.
Signature of Patient or Parent/Guardian of Minor
Patient
Vaccine Name Lot # Expiration Date Manufacturer Dose (ml) Dose # Route Site (circle) VIS/EUA
R / L Deltoid
R / L Deltoid
Signature of RPh: __________________ Initials of Administrator: ________ Administration Date: _____________ NPP Offered:
indicates (1) VIS/EUA Provided and (2) Counseling offered (Please circle)
(off-site only)
Medicare (ID# including letters) or Medical (Name, ID#, Group#, Payer ID) if UHC)
PCN: ______________ Group#: ______________
