Immunizations VAR New 2023

Please Select Your Appointment Time*

Appointment Date and Time

Name*

Date of Birth*

Date

Age*

Sex Assigned at birth:*

MaleFemale

Address*

City*

State*

Zip*

Phone*

Consent to text cell:*

YesNo

Email*

example@example.com

Race*

Ethnicity*

Primary Care Physician*

For Medicare Patients Only, Medicare Part B ID

Immunization*

Which COVID shot would you like?

For your shingles immunization is this dose 1 or dose 2?

Which arm do you prefer for vaccine?*

LeftRight

Are you feeling sick today?*

YesNo

Do you have any allergies to medications, foods or vaccines?*

YesNo

If yes, please list*

Do you have a medical condition(s) or take medication(s) that weaken your immune system (e.g. cancer, HIV, transplant)*

YesNo

If yes, please list*

Have you ever had a serious reaction or fainted after receiving a vaccination?*

YesNo

If yes, please describe*

For women: Are you pregnant or planning to become pregnant in the next month?

YesNo

By my signature below, I consent to the administration of the immunization(s) by a pharmacist or a supervised student pharmacist or technician, or other authorized person, where permitted by law or state/federal guidance, employed by Lehan Drugs Inc. The above information is true and correct. I attest I meet eligibility criteria for the vaccination (if any); if am the parent/guardian of the minor patient, I attest the minor patient meets eligibility criteria for the vaccination. I also release Lehan Drugs and employees from all liability, including acts of omission or commission, resulting, or arising from my receipt or the minor's receipt of this vaccination. I understand: 1) I have voluntarily chosen to receive the vaccination. 2)I authorize Lehan Drugs to submit a claim for reimbursement on my behalf to Medicare or any other contracted third-party payor, including my employer if they are paying directly for my vaccination; if the claim is denied, I understand I will be responsible for payment; 3) I am of legal age and authorized to execute this consent form or am the parent/guardian of the minor patient. 4) I will immediately alert the pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. 5) I have been counseled about the vaccination and I am responsible for following up with my physician at my expense if I experience any side effects. 6) I should remain in the area for observation for a minimum of 15 minutes. If I leave the area without waiting, I acknowledge that I am doing so at my own risk and against the advice of the professional who administered the vaccine. 7) I have been given the Vaccine Information Statement(s) ("VIS") or Emergency Use Authorization ("EUA") provided for the immunization(s) to be administered. I have had the opportunity to ask questions. I understand the benefits and risks of the immunization(s). 8) I have been offered and/or provided a copy of the company's Notice of Privacy Practices in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 9) This vaccination is subject to reporting by my pharmacy or its business associate to an immunization registry, which may share my immunization data with others, and to my primary care physicion, or the authorizing physician and I authorize these disclosures. I have read the consent form above and by signing, I give my consent.

Signature of Patient*

Relationship to Patient*

Date*

Date

Vaccine Administration Record (VAR) - Informed Consent for Vaccination