Flu Shot Consent Form

account_circlePatient Info
local_hospital
Please answer the questions below:
1. Do you have allergies to medications, food (e.g., eggs), yeast, a vaccine component, or latex?
2. Have you ever had a serious reaction (including fainting) after receiving a vaccination?
3. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside a medical setting?
4. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease?
6. In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
7. Have you had a seizure or a brain or other nervous system problem or Guillain-Barré?
8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
9. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
10. Have you received any vaccinations in past 4 weeks?
11. Would you like to request age 65+ Influenza Vaccine?
12. How would you like to receive your service?
Please take a picture of the front of your insurance card. This is not required, but it will help expedite your visit when you arrive.
Medicare patients: Please submit a copy of your red, white, and blue card - click here for an example.
add_a_photoTake photo
Please fill out your insurance information. This is not required, but it will help expedite your visit when you arrive. If you would like to upload an image of your insurance card, please click here.
Medicare patients: Please use your Red, White, and Blue Card - click here for an example. Your card will not have a BIN, PCN, or Group.
Please select an available date and time when you would like to visit. This will help us expedite your visit. Please arrive any time within your desired 30 minute window. If for any reason you are unable to make it in time, that is OK, please still visit us during normal business hours and we will happily assist you. Our address is:
Sona Pharmacy + Clinic
828-298-3636
805 Fairview Rd, Asheville NC, 28803
Mon-Fri: 8am-8pm, Sat: 9am-6pm, Sun: 11am-6pm
event
schedule
schedule
Please Read and Sign
I certify that I am at least 18 years old or that I am the parent or legal guardian of the minor patient (6-17 years of age for influenza only) or the legal guardian of the patient. I hereby give my consent to the staff of Sona Pharmacy to administer vaccine(s) that I have requested. I understand that is not possible to predict all possible side effects or complications associated with vaccines. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance ask questions. I, on the behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns herby agree to release, indemnify, and hold harmless Blue Ridge Pharmacy, Inc., its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccines listed above. I authorize Blue Ridge Pharmacy, Inc., as applicable, to release my medical or other information to, or through, the NC Immunization Registry to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, submit a claim to my insurer for the above requested vaccine(s), and request payment of authorized benefits to be made on my behalf to Blue Ridge Pharmacy, Inc., as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any co-sharing amounts, including copays, co-insurance, and deductibles, for the requested vaccine(s) including any not covered by my insurance benefits. I understand that if my insurance denies my claim for any reason, I will receive a bill for the above requested vaccine(s) from Blue Ridge Pharmacy, Inc.
Sign Above
PHARMACY STAFF ONLY
Please ask the patient: Are you sick today?
Immunizer Signature (Sign Above)
Intern Signature (Sign Above)
Complete And Submit To Pioneer