Pneumonia Vaccination - Assessment, Release & Consent Form
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3Pneumonia Vaccination
Assessment, Release & Consent Form
Date: ____‐____‐____
Name: ________________________________ DOB:______‐______‐______ Age:___________ Sex: M / F
(Circle One)
Address: ____________________________________________ City:__________________ State:____ Zip:________
Phone #_______‐______‐__________
Please have ALL OF YOUR INSURANCE CARDS out and ready for a Kohll’s employee to copy and attach to this form.
Primary Insurance:_________________________________ Policy #________________________Group #____________
Is this a Medicare HMO/Advantage Plan? Yes / No
(Circle one)
Do you have Medicare Part A (hospital) and Medicare Part B (medical)? Yes / No
(Circle One)
PLEASE CIRCLE THE ANSWERS TO THE FOLLOWING QUESTIONS:
1. Have you ever had a severe reaction to any vaccine?
YES
NO
2. Do you have any severe drug or food allergies?
YES
NO
If yes, are you allergic to PHENOL OR ANY DIPTHERIA TOXOID‐CONTAINING VACCINE?
YES
NO
If yes, are you allergic to POLYSORBATE 80, ALUMINUM OR YEAST?
YES
NO
If yes, please specify:____________________________________________________
3. How are you today? Do you have any substantial fever, diarrhea, or vomiting?
YES
NO
4. Have you received the pneumonia vaccine previously?
YES
NO
If yes, what date did you receive this vaccine? _________‐_________‐________
Women:
5. Have you had a mastectomy?
YES
NO
6. Are you pregnant?
YES
NO
I have read the above information or have had the information explained to me. I have had a chance to ask questions
and these have been answered to my satisfaction. I understand the benefits and the risks of the pneumonia vaccine and
ask that the vaccine is given to me, or to the person named above for whom I am authorized to make this request. I
accept responsibility for seeking medical attention for any problems with this vaccination. I authorize billing of this
vaccination to my health insurance. If for any reason my insurance does not pay for the vaccination, I agree to pay the
full amount of the procedure.
Signature: _________________________________________________________________Date:______‐______‐______
To be completed by store personnel:
⃝ Pneumovax 23 ⃝ Prevnar 13
Insurance Card Copied?______ Paid Cash:______
Store Location: V.I.S. 4/24/15
Shot Location L or R Deltoid Initials__________
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