501-pharmacy-vaccination | Immunizations and Vaccines

First Name

Last Name

Phone NumberOptional

Gender

MaleFemalePrefer Not to Answer

Address

Date of Birth

Which vaccine(s) would you like to receive?

Priorix (Measles, Mumps, Rubella)Moderna COVID Vaccine(Ages 12& up)Pfizer COVID Vaccine (Ages 12&up)Pneumonia (Capvaxive)Shingles (ages 50+) - First Shot in SeriesShingles (ages 50+) - Second Shot in SeriesTdap (Tetanus, diphtheria, and pertussis)RSV Vaccine (Abrysvo) - for ages 60+ (only needed once per lifetime)

Insurance CarrierOptional

Insurance Member IDOptional

Last Four of Social Security NumberOptional

If you do not have your insurance information available, we can look up most insurance plans with the last four digits of your social security number.

Do you have a health condition or are you undergoing treatment that makes you moderately or severely immunocompromised?

NoYes

This could include treatment for cancer or HIV, organ transplant, high-dose corticosteroids, etc.

Have you ever had a seizure or brain disorder, Guillian-Barre Syndrome, or other nervous system problem?

NoYes

Do you have any chronic health conditions such as diabetes, chronic kidney disease, chronic lung disease, obesity, sickle cell disease, heart disease, tobacco alcohol use?

NoYes

For Women Only: Are you pregnant or is there a chance you could become pregnant during the next month?Optional

NoYes

For Tetanus Only: Do you have an open wound, puncture, or tissue tear that prompted you to get a tetanus shot?Optional

NoYes

Signed Date

Consent for Services: Type Full Name Below to Sign

I hereby 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 501 Pharmacy pharmacist, or intern under the direct supervision of the pharmacist, to administer the vaccines I have elected to receive. I also acknowledge that I have had a chance to ask questions and such questions were answered to my satisfaction. I understand it is not possible to predict all possible side effects or complications associated with receiving vaccines. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the ministering provider. On behalf of myself, my heirs, and personal representatives, I hereby release and hold harmless 501 Pharmacy, its staff, agents, 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 vaccines listed above. I understand that my state may offer participation in a state immunization registry, in which case my immunization information may be supplied to the state unless I complete a state-approved opt-out process. 501 Pharmacy will, if my state permits, provide me with an opt-out form. Unless I provide 501 Pharmacy with a signed opt-out form, I elect to participate fully in, and consent to 501 Pharmacy reporting my immunization information to the state's immunization registry. I authorize 501 Pharmacy to release my medical or other information to my healthcare professionals, Medicare, Medicaid, or other third-party payers as necessary to facilitate care or payment submit a claim to my insured for the above-requested items and services, and request payment of authorized benefits to be made on my behalf to 501 Pharmacy with respect to the above-requested items and services. I further agree to be fully financially responsible for any due amounts, including co-pays, coinsurance, and deductibles for the requested items and services as well as for any requested items and service that is 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 if 501 Pharmacy invoices me after the time of service, upon receipt of such invoice.