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 regarding other immunizations for which I
am due or eligible to receive. I also release Albertsons Companies and its subsidiaries, affiliates, officers, directors, em
ployees, 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 understand that I
am obligated to pay for all products and services recei
ved, if applicable. 2) I may be responsible for payment after the date of service if the product or service is billed to my m
edical
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 w
here I should seek treatment. I am responsible for following up with my physician at my expense if I experience any side effe
cts. 6) I should remain in the
area for 15 minutes after the vaccination for observation. 7) I have read, or have had read to me, t
he 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 questions have been answered to my satisfaction. I understand the
ben
efits 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 Accountability Act (HIPAA). 9) 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 p
rimary care physician, the author
izing physician,
or the local Department of Health, if applicable, and I authorize these disclosures.
I understand I have the right to object to the sharing of my data to the above-
mentioned
parties through such registries.
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 _______
Signature of RPh: __________________ Initials of Administrator: ________ Administration Date: _____________ NPP Offered:
RPh Signature indicates (1) VIS/EUA Provided and (2) Counseling offered (Please circle) Accepted Declined
Billing Info (off-site only):
Medicare (ID# including letters) or Medical (Name, ID#, Group#, Payer ID - if UHC)
PCN: ______________ Group#: ______________
