Vaccination Consent Form Please fill out the vaccination consent form below. Name(Required) First Middle Last Address(Required) Street Address County City ZIP Code PhoneBirth Date Month Day Year AgeSex Male Female BIN PCN ID Group The following questions will help us determine if there is any reason we should not give you the injectable vaccine todayVaccine Flu Shot Flu HD (65+) Please check the box for the vaccine you are requesting to have administered todayHave you received any other vaccines in the past 4 weeks?(Required) Yes No If yes, which vaccine(s)?(Required) Are you sick today?(Required) Yes No Have you ever had a serious reaction after receiving a vaccine?(Required) Yes No Do you have an allergy to eggs or to a component of the vaccine?(Required) Yes No Have you ever had Giullian-Barre Syndrome?(Required) Yes No Please review the information sheet that is included. The influenza vaccine is composed of killed influenza viruses and will not give you the flu. As stated, it takes up to 2 weeks for protection to develop after the vaccination. IF YOU HAVE A REACTION, YOU SHOULD CONTACT YOUR PRIMARY CARE PHYSICIAN.Signature - Patient or Authorized Representative(Required)I have been provided a copy of the Vaccine Information Sheet and had the opportunity to ask questions. I understand the benefits and risks of the specific vaccine as described. I request that the vaccine begiven to me or the person for whom I am authorized to sign. I acknowledge that no guarantees have been made concerning the results of the vaccine. I hold harmless, Watkins Pharmacy & Surgical Supply Co. (the company), its employees, and the facility in which the vaccine was received. In the event that a company employee is exposed to my blood or other bodily fluids, I agree to have my blood tested for HIV and Hepatitis and have the results released to the company. I HAVE BEEN INFORMED THAT I AM RESPONSIBLE TO REIMBURSE THE COMPANY FOR CHARGES NOT COVERED. I hereby acknowledge my understanding of HIPPA privacy rights/Client Bill of Rights and notification that information regarding this vaccine will be entered into the MICR system and havebeen offered the written notices of all,Reason Patient Is Unable to Sign Use this if an authorized representative is signingDate Given MM slash DD slash YYYY Δ
