Pharmacy Vaccine Administration Consent Form

Patient Information

Full Name

Date of Birth

Address

Phone

Vaccine Information

Vaccine Name

Manufacturer

Lot Number

Expiration Date

Health Screening

History of severe allergy (anaphylaxis) to vaccine or component

Currently feeling sick

Pregnant or breastfeeding

Other medical conditions or allergies

Consent and Authorization

I acknowledge that I have read, or have had explained to me, information about the vaccine. I have had a chance to ask questions and my questions were answered to my satisfaction.

I consent to receive the vaccine as indicated above.

Patient/Guardian Signature

Date

Pharmacist Name

Pharmacist Signature

Date