Immunizations Form

Fill out the immunizations form below and a team member shall get back to you shortly.

Name
Address
Sex

For Inactive and Live Vaccines

Precautions and Contraindications: Please mark YES or NO for each question.
Are you 18 years of age or older?
Do you have a cold, fever, or acute illness?
Do you have any allergies to medications, food, or any vaccine? If YES, please list:
Are you allergic to chicken eggs or egg product?
Are you allergic to Thimerosal (cleaning products or contact lens solution)?
Have you ever had a serious reaction after receiving a vaccination?
Have you ever been diagnosed with Guillian-Barre Syndrome?
Do you have a seizure, brain, or nerve problem?

For Live Vaccines Only

Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs?
Do you live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation?
During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin?
For women: Are you pregnant/is there a chance you could become pregnant during the next month?
Have you received any vaccinations in the past 4 weeks?
Do you have a long-term health problem such as heart, lung, kidney, liver, or metabolic disease (e.g. diabetes), neurologic or neuromuscular disease, anemia or other blood disorder?
If you answered “YES” to any question, you must talk with your pharmacist before being vaccinated.
By submitting this form, I acknowledge that I have heard or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had an opportunity to ask the pharmacist any questions about the vaccine or about information in the VIS and my questions have been answered to my satisfaction. I have truthfully answered all the questions regarding my medical history that are listed above. I understand that if I answered a question with a “Yes” there is an increased likelihood that I will experience an adverse reaction from the administration of the vaccine. I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area for 20 minutes after the administration of the immunization. I acknowledge receipt of Sutton Family Pharmacy’s Notice of Privacy Practices for Protected Health Information. If applicable, I authorize Sutton Family Pharmacy to submit a claim to my insurer for this health care service and authorize an assignment of my insurance benefits under such claim to Sutton Family Pharmacy. I will be financially responsible for any copays, coinsurance and deductibles for the requested services as well as for any services not covered by my insurance benefits. I authorized Sutton Family Pharmacy to use and/or disclose such information about me, including any medical related information that I provide to the pharmacy or that is created or received by the pharmacy that the pharmacy reasonably determines is necessary to receive payment for its services, carry out my treatment or conduct its health care operations. This authorization includes disclosures to regulatory agencies, Medicare, Medicaid, health plans, pharmacy benefit managers, claims processors, billing companies, interpreters and other persons involved in my treatment, as well as any state immunization registry. Sutton Family Pharmacy shall not, at any time, or to any extent allowable by applicable law, be liable, responsible, or in any way be accountable for any loss, injury, death, or damage suffered or sustained by me or any other person at any time in connection with, or as a result of, the administration of the vaccine to me by the pharmacist. I, for myself, my heirs, executors, personal representatives and assigns, hereby release Sutton Family Pharmacy, its employees and contractors, specifically the administering pharmacist, its agent or representatives from any and all claims arising out of, in connection with, or in any way related to my receipt of the vaccine from Sutton Family Pharmacy as allowed by applicable law. By signing below, I certify that I am the patient or the patient’s guardian/personal representative signing on behalf of the patient, and that I have read, understand and agree to all statements on this form.