VACCINATION CONSENT FORM

Patient Name

First ______________________________________ Last _______________________________________

Address

______________________________________________________________________________________

______________________________________________________________________________________

Date of Birth

(mm/dd/yyyy)

__________________________________________ Phone Number _____________________________

Emergency Contact

Name _____________________________________ Phone Number _____________________________

Health Card Number

__________________________________________

Please answer the following questions:

As of Today:

Yes

No

Is this the first time you are receiving this vaccine?

Have you ever fainted or had a serious reaction to any previous vaccine(s)?
Have you received any vaccinations in the last 6 weeks?
Do you have a fever, an active infection, or feel unwell?
Are you allergic to:
o eggs
o egg products

o Thimerosal (a preservative)

o latex

o medications

If yes, please describe the reaction: _________________________________________________

________________________________________________________________________________
Do you have any chronic health conditions or immunodeficiencies?
(eg: asthma, diabetes, HIV, cancer)
If yes, please list: _________________________________________________________________
________________________________________________________________________________
Are you currently on any medications or immunosuppressants?
If yes, please list: _________________________________________________________________
________________________________________________________________________________
Do you have an active neurological condition (seizure disorder)?
Do you have any bleeding disorders or are you taking any blood-thinners?
If female, are you pregnant or breast feeding?
Side effects from vaccination typically resolve within 2 to 3 days and in most cases, an analgesic such as acetaminophen or ibuprofen may be
taken to reduce fever and/or discomfort.
Common side effects: soreness, tenderness, redness, and/or swelling in the area of the injection site.
Less frequent side effects: mild fever, headache, and/or muscle aches.
Due to a very rare possibility of an allergic or other reaction (about 1 for every one million vaccinations), please remain in the pharmacy for at
least 20 minutes after your vaccination.
If you develop a high fever or unexpected or prolonged side effects (lasting more than 2 days after vaccination), contact your doctor promptly.

PATIENT CONSENT
I have read and understood the information provided to me regarding the benefits, side effects, and risks associated with the following
injections (as indicated on the back of this form) administered today.
I have had the opportunity to have my questions answered.
I/my dependent, agree to remain at the pharmacy for at least 20 minutes following immunization.
I authorize my pharmacist to administer epinephrine and/or life-saving procedures in the event of a severe allergic reaction.
I authorize my pharmacist to contact me about a follow-up dose if required.
I hereby give my consent to receive the injections (indicated on Page 2) today, and release Pharmasave #__________ and the vaccinating
pharmacist/health care professional _____________________________ from any and all liability.
Print Name
Date

__________________________________________ Signature __________________________________________

__________________________________________

S4-146 Vaccination Report-R2.indd 1

10/14/10 11:37:48 AM

FOR VACCINATING PHARMACIST / HCP ONLY

Date __________________________________________ Patient Name _______________________________________________
Injection Site

o Left deltoid
Vaccine Information Table:

o Right deltoid

o Other _______________

Administration Record

Vaccination

Trade Name/Lot No./

Expiry Date

Hepatitis A

Trade Name ____________________ 1 - 18 yrs: 0.5mL

o IM
o 1 ________
Lot No _________________________ 19+ yrs: 1.0 mL
o 2 ________
Expiry Date _____________________

Dose 2: 6 months

Hepatitis B

Trade Name ____________________ 1 - 18 yrs: 0.5mL

o IM
Lot No _________________________ 19+ yrs: 1.0 mL
Expiry Date _____________________

o 1 ________
o 2 ________
o 3 ________

Dose 2: 1 month
Dose 3: 6 months
Date: _____________________

Hepatitis A & B

Trade Name ____________________ Twinrix: 1.0 mL

o IM
Lot No _________________________ Twinrix Jr: 0.5 mL
Expiry Date _____________________

o 1 ________
o 2 ________
o 3 ________

Dose 2: 1 month
Dose 3: 6 months
Date: _____________________

Influenza

Trade Name ____________________ 1 - 3 yrs: 0.25 mL

o IM
o 1 ________
Lot No _________________________ 3+ yrs: 0.5 mL
o 2 ________
Expiry Date _____________________

Dose 2: 1 month (only if <9 yrs.

& previously unvaccinated)
Date: _____________________

Pneumococcus

Trade Name ____________________ All ages: 0.5 mL

o IM
o 1 ________
Lot No _________________________
o SC
o 2 ________
Expiry Date _____________________

Date: _____________________

Human Papilloma
Virus

Trade Name ____________________ 9 - 26 yrs: 0.5 mL

o IM
Lot No _________________________
Expiry Date _____________________

o 1 ________
o 2 ________
o 3 ________

Dose 2: 2 months
Dose 3: 6 months
Date: _____________________

Tetanus/Diphtheria

Trade Name ____________________ All ages: 0.5 mL

o IM
o 1 ________
Lot No _________________________
o 2 ________
Expiry Date _____________________

Date: _____________________

Tetanus/Diphtheria/
Polio

Trade Name ____________________ All ages: 0.5 mL

o IM
o 1 ________
Lot No _________________________
o 2 ________
Expiry Date _____________________

Date: _____________________

Measles/Mumps
Rubella

Trade Name ____________________ All ages: 0.5 mL

o IM
o 1 ________
Lot No _________________________
o SC
o 2 ________
Expiry Date _____________________

Herpes Zoster
(shingles)

Trade Name ____________________ 60 yrs +

o SC
o 1 ________
Lot No _________________________
Expiry Date _____________________

Other:

Trade Name ____________________

Lot No _________________________
Expiry Date _____________________

Checklist:

o
o
o

Obtained signed informed consent from patient

(purpose of vaccine, risks vs. benefits)

Dosage
(circle)

Dosage
Dose Number
Form (check) (check)/Initial

Next Dose Schedule

(# months after 1st dose)

Date: _____________________

Dose 2: 1 month
Date: _____________________
Primary dose only

P
 atient understands common side effects and how to seek
help if adverse reactions persist

o Patient has a copy of updated immunization records

Patient has remained in the pharmacy for at least 20 minutes
Patient has documentation of next dose schedule: _____________________________ (mm/dd/yyyy)

Vaccinating Pharmacist/HCP Name

Vaccinating Pharmacist/HCP Signature

VCF-01 / Oct., 2010

S4-146 Vaccination Report-R2.indd 2

10/14/10 11:37:48 AM