Pharmacy Walk-In Vaccine Consent Form

Patient Information

Full Name

Date of Birth

Address

Phone Number

Vaccine Information

Vaccine Type

If Other, specify:

Health Screening

Are you feeling sick today?

Yes No

Allergic to any vaccine, food, or medicine?

Yes No

If yes, please list allergies:

Have you ever had a severe reaction after receiving a vaccination?

Yes No

Consent

By signing below, I consent to receive the above vaccine and acknowledge that I have read the Vaccine Information Statement and was given the opportunity to ask questions.

Signature

Date