Fillable Shoprite Vaccine Administration Consent Form printable pdf download

ShopRite Vaccine Administration Consent Form

INFORMATION ABOUT VACCINEE (PLEASE PRINT CLEARLY) – VACCINEE OR LEGAL GUARDIAN MUST SIGN BELOW

NAME (Last)*

(First)*

(M.I.)

DATE OF BIRTH*

_______ / _______ / _______

month /

day

year

MAILING ADDRESS*

GENDER*

MALE

FEMALE

CITY*

STATE*

ZIP*

TELEPHONE*

e-Mail

VACCINEE’S PRIMARY PHYSICIAN

PHYSICIAN’S ADDRESS & CONTACT INFO

MISCELLANEOUS/Documentation of contacting patient’s PCP (Maryland Only)

INSURANCE INFORMATION

*Required Information

SCREENING FOR INJECTABLE VACCINE ELIGIBILITY*

SCREENING QUESTIONS (Type an “X” under either the YES or NO field for each question)

YES

Are you sick today? Do you have a fever, diarrhea, or vomiting today?

Are you allergic to eggs, Baker’s yeast, preservatives, sulfites, thimerosal, streptomycin, neomycin, arginine, gelatin or latex?

Have you ever had a serious reaction to any vaccine?

Are you, anyone in your home, or anyone you take care of being treated with chemotherapy or radiation for Cancer, Leukemia,

have HIV/AIDS or any immune deficiency disorder?

Have you had Immune (Gamma) Globulin, a blood transfusion, blood products, plasma, or an antiviral drug in the past year?

Have you had Guillain-Barre Syndrome, a condition which causes paralysis?

Are you taking any blood-thinning medications (i.e. aspirin, warfarin, etc.)?

Have you received any immunizations in the last 30 days?

Do you have any medical conditions such as: Heart Disease, Lung Disease, Asthma, Kidney Disease, Liver Disease, Metabolic

Disease (e.g. Diabetes), Anemia, or other Blood Disease?

For Tdap Only: Do you have progressive or unstable neurologic disease, uncontrolled seizures, or progressive

encephalopathy?

For Women Only: Are you pregnant or planning pregnancy in the next month?

* NOTE: At the sole discretion of the Pharmacist, a “YES” answer to any of these questions may warrant referral to a

Physician for further evaluation to determine the eligibility of the person to receive a vaccination.

PHARMACY USE ONLY

ADMINISTERING RPh: __________________________________

RPh SIGNATURE: ____________________________________________

Vaccine

Date of Dose &

Dose #

Vaccine

Dose

Route/Site

Lot Number

Exp Date

VIS Provision

Manufacturer

, 2

, etc.)

Seasonal

Influenza

Arm

Leg

PPSV

Arm

Leg

Zoster Vaccine

Arm

Leg

IM (Deltoid)

Tdap

VIS Version

INFLUENZA: __________ PPSV: ____________ ZOSTER: __________ Tdap:__________ Other: ___________

CONSENT STATEMENTS FOR VACCINATION

I have read and understand the statements written on the back of this form. I GIVE CONSENT to ShopRite Pharmacy #________ and

associated staff to administer this vaccine(s) to me or, if applicable, to this individual as his/her legal guardian. I understand that the

information contained within this record is being maintained to monitor immunization needs in order to prevent disease.

This

information is confidential and will only be shared with organizations or persons who are authorized by law to receive it. (If the

dosing consent statement of this form is not signed, dated, and returned, the person named above will not be vaccinated.)

DOSING CONSENT:

PRINT VACCINEE/LEGAL GUARDIAN NAME: _________________________________________

DATE: _____________________

VACCINEE/LEGAL GUARDIAN SIGNATURE: ___________________________________ RELATIONSHIP:_____________________

VACCINE REGISTRY CONSENT: YOUR SIGNATURE BELOW AUTHORIZES THIS PHARMACY TO SUBMIT A RECORD OF THIS/THESE

VACCINATION(S) TO YOUR RESPECTIVE STATE’S VACCINE REGISTRY WHERE APPLICABLE.

VACCINEE/LEGAL GUARDIAN SIGNATURE: ____________________________________________________________________

Wakefern GW – Pharmacy Division Form # 11-7910010

Shoprite Vaccine Administration Consent Form

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