Vaccination Consent Form

Vaccination Consent Form
SECTION A: Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
AGE:
GENDER

MaleFemale
PHONE NUMBER
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECTION B: Screening Questions

Choose Yes or NO
1. Do you feel sick today?

YesNo
2. Do yo uhave allergies to medications, food, a vaccine component (such as neomycin), or latex

NoYes: please specify
3. Have you ever had a serious reaction after receiving vaccination?

YesNo
4. Have you ever fainted after an injection?

YesNo
5. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (such as diabetes), anemia or other blood disorder?

YesNo
6. Do you have cancer, leukemia, HIV/AIDS or any other immune system problem?

YesNo
7. In the past 3 months have you taken medications that affect your immune system such as prednisone, other steroids, anticancer drugs, drugs for treatment of Rheumatoid Arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatment?

YesNo
8. Have you had a seizure or a brain or other nervous system problem?

YesNo
9. During the past year, have you received a transfusion of blood or blood products or been given immune (gamma) globulin or an antiviral drug?

YesNo
10. Have you received any vaccinations in the past 4 weeks?

YesNo
11. For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNo
SECTION C:
I certify that I am the patient and am at least 18 years of age (or parent/legal guardian of patient). I am providing information on this form that is accurate to the best of my knowledge. I give my consent to the healthcare provider (pharmacist) at Rogue Community Health to administer the vaccination I have requested above. I understand the risks and benefits associated with the vaccine and have received the Vaccine Information Statement relating to the vaccine listed above. I acknowledge that it is advised to remain near the vaccination administration area for at least 15 minutes so I can be monitored by healthcare provider for possible signs of adverse reaction(s). I have received this clinic’s HIPAA Notice of Privacy Practices.
Patient Signature
Date

MonthDayYear
Date
Should be Empty:

Vaccination Consent Form

SECTION A: Patient Information

SECTION B: Screening Questions

SECTION C: