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CarePlusRx Consent & Booking

Name of Organization

Patient Information

Full Name

Date of Birth

Date of Birth

Address

City

State

Zip Code

Email Address

Phone Number

Sex at Birth

Sex at Birth
A
B

Age

Weight (if under 110 lbs)

Race

Race (Select all that apply)
Untitled multiple choice field
A
B
C
D
E
F

Primary Care & Known Medical Condition

Do you have any medical conditions? Please list them below.

Primary Care Physician (PCP) Name

PCP Address (City, State, Zip)

Do you authorize the pharmacist to send copies of your vaccine documents to your primary care provider?

Do you authorize the pharmacist to send copies of your vaccine documents to your primary care provider?
A
B
*Note: If left blank, documents may be sent as required by state laws.*

Pre-Vaccination Screening (Yes / No / Don’t Know)

Are you sick today?

Are you sick today?
A
B

Do you have heart disease, kidney disease, metabolic disorder (e.g. diabetes), anemia or other blood disorders?

Do you have heart disease, kidney disease, metabolic disorder (e.g. diabetes), anemia or other blood disorders?
A
Untitled multiple choice field
A
B

Do you have lung disease or asthma?

Do you have lung disease or asthma?
A
B
C

Do you smoke?

Do you smoke?
A
B
C

Do you have allergies to medications, food (e.g. eggs), latex, or any vaccine components (e.g. neomycin, formaldehyde, thimerosal, gelatin)?

Do you have allergies to medications, food (e.g. eggs), latex, or any vaccine components (e.g. neomycin, formaldehyde, thimerosal, gelatin)?
A
B
C

Have you received any vaccinations in the past 4 weeks?

Have you received any vaccinations in the past 4 weeks?
A
B
C

Have you ever had a serious reaction after receiving a vaccine?

Have you ever had a serious reaction after receiving a vaccine?
A
B
C

Do you have a neurological disorder or history of vaccine-related disorders (e.g. Guillain-Barre Syndrome)?

Do you have a neurological disorder or history of vaccine-related disorders (e.g. Guillain-Barre Syndrome)?
A
B
C

Do you have cancer, leukemia, AIDS, or any immune system problem?

Do you have cancer, leukemia, AIDS, or any immune system problem?
A
B
C

Do you take steroids, anticancer drugs, or have you had radiation therapy?

Do you take steroids, anticancer drugs, or have you had radiation therapy?
A
B
C

Have you received a transfusion of blood or blood products in the past year?

Have you received a transfusion of blood or blood products in the past year?
A
B
C

Are you a parent, family member, or caregiver to a newborn infant?

Are you a parent, family member, or caregiver to a newborn infant?
A
B
C

For women: Are you pregnant or could you become pregnant in the next 3 months?

For women: Are you pregnant or could you become pregnant in the next 3 months?
A
B
C

Vaccine History

Vaccine History
Untitled checkboxes field

Services Requested
Which vaccine(s) would you like to receive today? (Select all that apply)

Services RequestedWhich vaccine(s) would you like to receive today? (Select all that apply)

Acknowledgment & Consent

Please check each box to confirm your understanding and consent:

I authorize the release of medical or other information for billing.
I acknowledge that my vaccination record may be shared with federal/state agencies.
I acknowledge the pharmacist recommends remaining for 15 minutes post-vaccination.
I acknowledge receipt of the Notice of Privacy Practices.
I understand that vaccination does not replace my regular checkup with my primary care provider.
I authorize billing of my insurance or third-party payer on my behalf.
I have read or had read to me the EUA/VIS for the vaccine(s) and understand the benefits and risks.
I consent to the administration of the vaccine(s).
I release CarePlusRx, its staff, and affiliates from any liability related to the vaccination.

Signature & Date

Patient Signature (Type your full name as signature)

Signature

Date