Immunization Consent Form

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Live
NASAL
INFLUENZA Immunization CONSENT FORM
, Intra
Name
FIRST: _____________________________________MIDDLE INITIAL:_____
(as it appears on Medicare card, if applicable):
LAST: _______________________________________________________________________________SUFFIX ( Jr., Sr., etc.)_______
ADDRESS:___________________________________________________________________________________________________
CITY:____________________________________________
STATE:_________
ZIP:______________
PHONE: (
)_______ - ______________
Date of Birth: ____ /____/_________
Sex (circle one): M
F
PAYMENT TYPE:
Cash/ Check
Kroger Employee: ID# _________________________________
Management
non-Management(use SSN)
(use RX card)
Other insurance: ID#______________________________ TP Code: ________ Group:___________________Person Code:_____
PRECAUTIONS and CONTRAINDICATIONS
1.
Are you between the ages of 2 years of age and 49 years of age?
1. _____________age of patient
A
prescription is necessary to administer this vaccine if patient is <9 y.o. in KY,and <14 y.o. in IN and TN)
2.
For women: Are you pregnant or could become pregnant in the next month?
2. Yes ________ No ________
(If yes, patient is NOT eligible to receive this vaccine)
3
.Do you have a fever or are you sick today?
3. Yes ________ No ________
4
. Do you have heart disease, lung disease, asthma, kidney disease, any metabolic disease
4. Yes ________ No ________
(e.g.diabetes), anemia, or other immune system disorders?
5
. Do you or anyone you are in contact with have a weakened immune system due to a disease 5. Yes ________ No ________
(leukemia/ lymphoma of any type, cancer(s), or HIV/AIDS), a medicine (high –dose steroids),
or any other immune system disorder?
6
.Have you ever had a serious reaction to any vaccine?
6. Yes ________ No ________
7
.Are you allergic to eggs, gentamicin, arginine, gelatin, or any other vaccine ingredients?
7. Yes ________ No ________
8
.Do you have a history of Guillain - Barré Syndrome or an active neurological disorder?
8. Yes ________ No ________
9
.Have you received any other vaccinations in the past 4 weeks?
9. Yes ________ No ________
10. Are you currently on any medication therapy (i.e. aspirin, aspirin containing therapy.
10. Yes ________ No ________
or antiviral therapy like Tamiflu or Relenza)?
CONSENT FOR SERVICE: I certify that I am at least 18 years old and hereby give my consent to the staff of Kroger Pharmacy to administer the vaccine(s) indicated
below. I have read the Vaccine Information Sheets(s) (VIS) for my vaccine and understand the benefits and risks of the vaccine and choose to assume that risk. As with
all medical treatment, there is no guarantee that I will not experience an adverse side effect from the vaccine(s). I fully release and discharge the standing order
physician, and Kroger Limited Partnership I, dba Kroger Pharmacy, its affiliates and their officers, directors, and employees from any liability for illness, injury, loss, or
damage which may result there from. I acknowledge that I have received a copy of the Kroger Company privacy policies, in accordance with HIPAA. I acknowledge
that I am in a high-risk group as defined by the CDC. (Applicable only when mandated by the CDC).
* I agree to wait near the vaccination area for approximately 20 minutes to receive treatment in case of an adverse reaction.
SIGNATURE
(or signature of guardian if under 18)__________________________________________________________________________
********************************************FOR PHARMACY USE ONLY******************************************************
VIS: 07/26/2011
LIVE, IntraNASAL Influenza Vaccine
0.2 ml
_____________________
________________________
®
FluMist
LOT #
EXP. DATE
Medimmune
Immunizer_________________________________________________PharmD/ RPh/Student
Date: ______________________
***********Place prescription back tag on the back of this document or store stamp with address****************
79

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