Medication Administration/immunization Consent Form - Pharmacist Immunization Program

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Medication Administration/ Immunization Consent Form
Name: ____________________________________________________ Phone: ______________________
Date of Birth: _____________________ Age: ______
Gender (circle one): Male / Female
Street Address: ____________________________________________________________________________
City: _______________________________ State: _________ Zip Code: ___________________________
Screening Questions (if you answer yes, please explain below)
Please circle
1.
Are you sick today?
Yes
No
2.
Do you have allergies to medications, food (esp. eggs), a vaccine component, or
Yes
No
latex? List all.
3.
Have you ever had a serious reaction after receiving a vaccination?
Yes
No
4.
Do you have a long-term health problem with heart disease, lung disease, asthma,
Yes
No
kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
5.
Do you have cancer, leukemia, AIDS, or any other immune system problem?
Yes
No
6.
Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you
Yes
No
had radiation treatments?
7.
Have you had a seizure or a brain or other nervous system problem?
Yes
No
8.
During the past year, have you received a transfusion of blood or blood products, or
Yes
No
been given immune (gamma) globulin or an antiviral drug?
9.
For women: Are you pregnant or is there a chance you could become pregnant
Yes
No
during the next month?
10. Have you received any vaccinations in the past 4 weeks?
Yes
No
Consent and waiver: I consent to the staff to administer the medication(s) mentioned below. I have reviewed the vaccine information sheet
(s) and understand the benefits and risks of receiving this medication and choose to assume this risk. I fully release and discharge the standing
order physician (Jennifer Dillaha, MD) and the pharmacy, its affiliations and their officers, and employees from any illness, injury, loss, or
damage that may result there from. I acknowledge that I have received a copy of the pharmacy’s privacy policies according to HIPPA. I assign
payment of authorized insurance benefits due to me to be paid to the pharmacy and will pay any copay or deductible that result. I consent the
release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any
medications received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be
administering this medication. I agree to wait near the vaccination area for approximately 20 minutes to receive treatment in case of
adverse reaction.
Signature of patient X:___________________________________________________ Date:_________________
Below is for pharmacy documentation
Medication:________________________________ VIS Date: ______________ Lot #:_______________ Exp Date: __________ Site: _______
Medication:________________________________ VIS Date: ______________ Lot #:_______________ Exp Date: __________ Site: _______
Administered by: ______________________________________ Title: ______________________ Date Given:__________________

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