Fillable Vaccine Blank Consent Form

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Vaccine Blank Consent Form

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  • 10 check-boxes
  • 52 other fields

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Aug 2020
V A C C I N E A D M I N I S T R A T I O N C O N S E N T F O R M
SECTION 1 – INFORMATION ABOUT THE PERSON RECEIVING THE VACCINE
Name: _________________________________ Date of Birth: ______ / _______ / __________ Phone: (________)__________________
Address: ____________________________________________ City: __________________________, TX Zip Code: _________________
Insurance Carrier Name: _____________________________ ID #: _____________________________ Group #: ____________________
Policy Holder Name (if different): _________________________________________ Policy Holder Date of Birth: ____________________
Vaccines Needed: Flu Pneumonia Shingles Td Tdap Hepatitis A Hepatitis B Meningitis HPV Other: ___________
**H-E-B Pharmacy will contact your primary care provider informing them of vaccine(s) given today using the information provided below**
Primary Care Provider Name: _____________________________ Phone: (_______)_______________ Fax: (_______)_______________
SECTION 2 – QUESTIONS TO DETERMINE VACCINE ELIGIBILITY (circle YES or NO)
1. In the last 10 days, have you or someone with whom you’ve been in close contact been diagnosed with COVID-19?
YES NO
2. Are you sick today or do you have any of these symptoms: fever, chills, shortness of breath, body aches, loss of taste/smell
YES NO
3. Do you have any long-term health conditions? (ex: heart disease, diabetes, asthma, COPD, kidney disease, anemia)
YES NO
4. Do you have allergies to medications, foods, or latex? (ex: egg, bovine, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast)
YES NO
5. Have you had any serious reactions from a vaccine?
YES NO
6. Are you taking biological injectables, steroids, anticancer drugs, antivirals, or have you had recent radiation treatments?
YES NO
7. Do you have a seizure disorder, brain disorder, Guillain-Barre Syndrome, or nervous system disorder?
YES NO
8. Do you have a problem with your immune system, history of AIDS, bone marrow disease or tuberculosis?
YES NO
9. During the past year, have you received blood or blood products or been given immune (gamma) globulin?
YES NO
10. Have you had any vaccinations in the past 4 weeks?
YES NO
11. Are you age 65 years or older? Age:
YES NO
12. FOR WOMEN: Are you pregnant, or is there a chance you could become pregnant in the next month?
YES NO
SECTION 3 – PLEASE READ CAREFULLY AND ACKNOWLEDGE WHERE APPROPRIATE
I hereby give my consent to the H-E-B Pharmacy (“H-E-B”) to administer the vaccine(s) (the “Services”) I have requested below. Legal effective July 22, 2016
With my initials, I certify that:
__________ I am: (i) the Patient and at least 18 years of age; (ii) the parent or guardian of the minor Patient; or (iii) the legal guardian of the Patient; or (iv) a person authorized under the
law of another state or a court order to consent for the child; OR
__________ The persons identified under (ii), (iii), or (iv), in the preceding sentence are unavailable and I have authority to consent to the immunization of the child because I am a (i)
grandparent; (ii) adult brother or sister; (iii) adult aunt or uncle; (iv) stepparent; or (v) another adult who has actual care, control, and possession of the child and has written authorization
to consent for the child from a parent, managing conservator, guardian, or other person who, under the law of another state or a court order, may consent for the child; additionally, I
certify that I do not have knowledge of any express refusals or withdrawn authorizations of consent and have not been told not to give consent for the child.
I understand that any Protected Health Information (“PHI”) I provide H-E-B will only be used or disclosed by H-E-B in accordance with H-E-B’s Health Insurance Portability and
Accountability Act (“HIPAA”) Notice of Privacy Practices. By signing below I acknowledge receipt of such HIPAA Notices of Privacy Practices and consent to the uses and disclosures of PHI
described therein. While H-E-B reserves the right to not do so, I consent to H-E-B reporting my immunization information to the State Immunization Registry. Should H-E-B elect to report
my immunization history to the Texas central immunization registry, ImmTrac, I further understand that my immunization information may be accessed by other health care providers,
educators, public health representatives, state agencies and certain insurance payers. I further authorize H-E-B to (1) release my medical or other information, including my communicable
disease (including HIV), mental health and drug/alcohol abuse information, to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care
or payment or otherwise, (2) submit a claim to my insurer for the below requested items and services, and (3) request payment of authorized benefits be made on my behalf to H-E-B with
respect to the below requested items and services. I further agree to be fully financially responsible for any co-sharing amounts, including copays, coinsurance, and deductibles, for the
requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible
is due at the time of service or, if H-E-B invoices me after the time of service, upon receipt of such invoice. Please note: for non-prescription insurance (i.e. medical/health insurance), your
insurance will notify you and H-E-B the exact copay/coinsurance amount due once they receive and process the claim. You may receive an invoice for any amounts due, up to and including
the total amount of the claim.
NOT A SUBSTITUTE FOR A PHYSICIAN
I understand that H-E-B Pharmacy representatives are not physicians trained to diagnose and treat medical problems. I acknowledge that the administration of Services does not
constitute, and should not be interpreted as, medical advice or opinions substituting for the advice of a physician. I understand that the administration of Services does not create a doctor-
patient relationship between myself and H-E-B. I agree to consult a physician if I require medical advice or services at any time.
RELEASE, IMDEMNITY AND DISCLAIMER
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the
below vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had
a chance to ask questions and that such questions were answered to my satisfaction. I additionally acknowledge that I have received a copy of the H-E-B Pharmacy notice of privacy.
Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering health
care provider. I understand that in the course of the requested vaccine administration, an H-E-B Pharmacy representative could possibly be exposed to my blood or bodily fluids. In such
event, I agree to review and execute the “H-E-B Post-exposure Consent for Testing” form.
On behalf of myself, my heirs and personal representatives, I further hereby WAIVE, RELEASE, and AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS (including for costs and
attorney’s fees) H-E-B, its staff, agents, employees and corporate affiliates from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way
related to the administration of Services listed below, even should such damages or losses result from H-E-B’s negligence.
s
Patient Signature: _____________________________________________________________________ Date: ______________________________
(Parent or Legal Guardian, if minor)
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Aug 2020
SECTION 4 – MEDICARE PART B USE ONLY
Medicare Part B Authorization Form
Statement to Permit Assignment of Medicare Benefits
• I understand that I am giving H-E-B Pharmacy permission to ask for Medicare payments for my medical care, including
supplies and equipment.
• I understand that Medicare needs information about me and my medical condition to make a decision about these
payments. I give permission for that information to go to Medicare and the companies that handle Medicare payment
requests.
• I understand that the Centers for Medicare & Medicaid Services (CMS) is the government’s Medicare agency. I understand
that a photocopy of this release is as valid as the original document. Furthermore, I understand that I am responsible for
paying any deductible or coinsurance amounts.
• Therefore, I ask that payment of authorized Medicare benefits be made to either me or on my behalf to H-E-B Pharmacy for
any services or items furnished to me by H-E-B Pharmacy. I authorize any holder of medical or other information about me
to release such information to the Centers for Medicare & Medicaid Services (CMS) and its agents as needed to determine
these benefits or benefits for related services.
Name: ____________________________________________ HICN:___________________________________
Signature: _________________________________________ Date:___________________________________
SECTION 5 – PHARMACY USE ONLY Temperature checked by (Partner initials): ________
Vaccine
Brand Name
Amount
Administered
Route
Lot Number
Site of
Administration*
Inactivated Influenza
Fluzone HD
0.7 ml
IM
RD LD
Inactivated Influenza
Flublok
0.5 ml
IM
RD LD
Inactivated Influenza
Fluad
0.5 ml
IM
RD LD
Inactivated Influenza
Flucelvax Quad
0.5 ml
IM
RD LD
Inactivated Influenza
Afluria Quad
0.5 ml
IM
RD LD
Inactivated Influenza
Fluarix Quad
0.5 ml
IM
RD LD
Inactivated Influenza
Flulaval Quad
0.5 ml
IM
RD LD
Inactivated Influenza
Fluzone Quad
0.5 ml
IM
RD LD
Hepatitis A
Havrix
0.5 ml / 1 ml
IM
RD LD
Hepatitis B
Heplisav
0.5 ml
IM
RD LD
Hepatitis B
Engerix
0.5 ml / 1 ml
IM
RD LD
Hepatitis A/B
Twinrix
1 ml
IM
RD LD
Herpes Zoster (shingles)
Shingrix
0.5 ml
IM
RD LD
HPV-9
Gardasil 9
0.5 ml
IM
RD LD
Meningococcal (ACWY)
Menveo
0.5 ml
IM
RD LD
Measles/Mumps/Rubella
MMR II
0.5 ml
SC
RA LA
Pneumococcal-23
Pneumovax 23
0.5 ml
IM / SC
RD/RA LD/LA
Pneumococcal-13
Prevnar 13
0.5 ml
IM
RD LD
Td (tetanus/diphtheria)
Tenivac
0.5 ml
IM
RD LD
Td (tetanus/diphtheria)
Tet/Dip
0.5 ml
IM
RD LD
Tdap (tet/dip/pertussis)
Boostrix
0.5 ml
IM
RD LD
Typhoid
Typhim
0.5 ml
IM
RD LD
Typhoid
Vivotif
4 caps
Oral
By Mouth
Varicella (chicken pox)
Varivax
0.5 ml
SC
RA LA
Other
* RD - Right Deltoid, LD - Left Deltoid, RA - Right Arm, LA - Left Arm
H-E-B Pharmacy Location
Vaccine Information Sheet (VIS)
To Be Completed by Immunizer
Corp #:
Address:
City, State:
Influenza (inactive/live) - 8/15/19
Pneumococcal PPSV23 - 10/30/19
Pneumococcal PCV13 - 10/30/19
Hepatitis A - 7/28/20
Hepatitis B - 8/15/19
Herpes Zoster - 10/30/19
HPV - 10/30/19
Meningococcal ACWY - 8/15/19
Meningococcal B - 8/15/19
Japanese Encephalitis - 8/15/19
MMR - 8/15/19
Td - 4/1/20
Tdap - 4/1/20
Varicella - 8/15/19
DTap - 4/1/20
Hib - 10/30/19
Polio - 10/30/19
Rabies - 1/8/20
Typhoid - 10/30/19
Cholera - 10/30/19
Pharmacist Initials: __________________
Signature: _________________________
Date of Immunization: _______________
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Vaccine Blank Consent Form

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Completed 31 December 2021

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