Vaccine Consent And Release Form

VALLEY MEDICAL PHARMACY
630 Main Street, Brawley, CA 92227
Phone Number: (760) 344-6303
Fax Number: (760)344-6321

Which Vaccines would you like to get? *

Street Address Line 2

City *

State

Zip Code *

Phone *

Email Address *

Bin Number

PCN Number

Group Number

ID Number

1. Do you have allergies to medications, food or vaccines? (Examples: Latex, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol or thimerosal) *

Yes

If yes, please list all allergies

2. Have you ever had a serious reaction to a vaccine in the past? *

Yes

3. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem? *

Yes

4. Are you sick today? (For example, cold, fever, or acute illness) *

Yes

5. Do you smoke? *

Yes

6. Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only) *

Yes

7. Have you received any vaccinations or skin tests in the past four weeks? *

Yes

If yes, please list

8. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *

Yes

9. Do you have a chronic condition or long-term health problem? *

Yes

10. Have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin in the past year? *

Yes

11. For women: Are you pregnant or plan to become pregnant or currently breastfeeding? *

Yes

12. Do you have a history of myocarditis/pericarditis (Inflammation of Heart) or Heparin-induced Thrombocytopenia (HIT) (Clotting)? *

Yes

I certify that I am: (i) the patient and at least 18 years of age; (ii) the parent or legal guardian of the minor patient; or (iii) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of administration of vaccine requested. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering healthcare provider. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Valley Medical Pharmacy, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that: I understand the purposes/benefits of my state’s immunization registry (“State Registry”). I acknowledge that, depending upon my state law, I may prevent, by using a state-approved opt-out form (“Opt-Out Form”): (a) disclosure of my immunization information to the State Registry; or (b) the State Registry from sharing my immunization information with any of my other healthcare providers enrolled in the State Registry. I authorize Valley Medical Pharmacy as applicable, to release my medical or other information to my healthcare professionals,Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf Valley Medical Pharmacy as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any co-sharing amounts, including co-pays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, upon receipt of such invoice.

Signature Of Patient/Employee/Legal Representative *

Clear

Relationship to Patient (if applicable)

Date

Anemia	Asthma	Diabetes
Heart disease	Kidney disease	Lung disease

American Indian or Alaska Native	Asian	Black or African American
Hispanic or Latino	Native Hawaiian or other Pacific Islander	White
Other

VALLEY MEDICAL PHARMACY