Immunization Consent Form PATIENT S LAST NAME PAT 2023-2026

Immunization Consent Form PATIENT S LAST NAME PATIENT S FIRST NAME MI Address City gender m/F State Zip 10-Digit Phone number medicare id number Birth date MM/DD/YYYY PRIMARY HEALTHCARE Prescriber PRescriber ADDRESS PRescriber PHONE/FAX Vaccine Requested Precautions and contraindications Please check yes or no for each question* r No 7. Have you had a seizure brain or nerve problem ............................................. r Yes. r No 2. Do you have allergies to medications food or vaccines ................................. r Yes. r No 8. During the past year have you received a transfusion of 1. Are you sick today ............................................................................................ r Yes. blood or blood products or been given a medicine called immune gamma globulin ................................................................................ r Yes r No Allergies ___________________________________________________________ 3. Have you ever had a serious reaction after receiving a vaccination .............. r Yes. 4. Do you have a long-term health problem with heart disease lung disease asthma kidney disease metabolic disease e*g* diabetes anemia or other blood disorder ..................................................................................... r Yes r No 5. Do you have cancer leukemia AIDS or any other immune system problem .r Yes. 6. Do you take cortisone other steroids or anti-cancer drugs or have you had X-ray treatments .................................................................... r Yes r No 9. women Are you pregnant or is there a chance you could For become pregnant during the next month ......................................................... r Yes r No 10. Have you received any vaccinations in the past 4 weeks ............................... r Yes. .f yes what vaccines _________________________________________________ I 11. Are you allergic to eggs ................................................................................... r Yes. Adverse reactions A vaccine like any medicine is capable of causing serious problems such as severe allergic reactions. The risk of any vaccine causing serious harm or death is extremely small* Local symptoms may include slight tenderness redness itching or swelling at the site of injection* Systemic symptoms may include fever malaise and muscle pain* Other systemic symptoms may occur infrequently. These reactions usually begin 6 to 12 hours after immunization and can persist for a few days. Immediate presumable allergic reactions such as hives angioedema allergic asthma or systemic anaphylaxis occur rarely after immunization* These reactions may result from hypersensitive reactions in people with severe egg allergy and such people should not be given certain vaccines that contain eggs. People with documented immunoglobulin E IgE mediated hypersensitivities to eggs or any other vaccine components including thimerosal may also be at increased risk of reactions from immunizations. In the case of a severe reaction such as a high fever behavior changes or flu-like symptoms that occur after vaccination see a doctor right away. Signs of an allergic reaction can include difficulty breathing hoarseness or wheezing hives paleness weakness a fast heartbeat or dizziness within a few minutes to a few hours after the shot. Administrative record FOR PHARMACY USE ONLY Vaccine ___________________ Expiration Date __________ VIS Version _________________ Site of Injection _________ Manufacturer _____________ Dosage _________________ Lot Number ________________ Route of Admin __________ Payment Information Total Charge Vaccine Fees I have read the adverse reactions associated with the administration of vaccines. A copy of the vaccine manufacturer s drug information sheet is available on request. Furthermore I have also had an opportunity to ask questions about these immunizations. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization s or the receipt of the immunization s by the person named below for whom I am the legal guardian Ward . My medical record may be shared with my physician or other healthcare provider and the medical record of my Ward may be shared with his/her physician or other healthcare provider. I am requesting that the immunization s be given to me or my Ward. I for myself and on behalf of my Ward and each of our respective heirs executors personal representatives and assigns hereby release Costco and its affiliates subsidiaries divisions directors contractors agents and employees collectively Released Parties from any and all claims arising out of in connection with or in any way related to my receipt and the receipt by my Ward of this or these immunization s . Neither Costco nor any of the Released Parties shall at any time or to any extent whatsoever be liable responsible or any way accountable for any loss injury death or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described above. Costco will use and disclose your personal and health information or the personal and health information of your Ward to treat you or your Ward to receive payment of the care we provide and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies in regard to you and your Ward s personal health information* I acknowledge that I have received a copy of the Notice of Privacy Practices. Signature/Legal Guardian date of vaccination/Date Vis Given Print Name Pharmacist/prescriber Signature Pharmacy name/address Please provide a copy of this form to your physician and/or healthcare provider for your permanent medical records. WHITE Administrative Copy YELLOW Patient Copy 12AB1202 7/12