Vaccine Consent Forms | Rains Pharmacy

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Employer/Campus

Are you 65 or older today?

Sex

Male

Female

Primary Care Doctor Name

Would you like a B12 Shot as well?

Are you feeling sick today?

Yes

Do you have any allergies to food (egg products), medicines or vaccines?

Have you ever fainted or had a serious reaction to a vaccine?

Are you pregnant or likely to become pregnant in the next 3 months?

Do you have cancer, AIDS, or another immune system issues?

Do you currently take any oral steroids, anti-cancer meds, radiation, or immune suppressing medications?

In the last year, have you received a blood transfusion, plasma, or immunoglobulin?

Do you have a brain disorder or suffer from seizures?

Have you received any vaccinations in the last 4 weeks?

Have you received TB skin test in the last week?

Date

Signature

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I accept terms & conditions

Insurance/Self Pay

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