Questions:
If patient is 60 or older, have you had a shingles shot?
Are you sick today?
Do you have a serious allergy to ANY medications or food? (ex. eggs, gelatin, Thimerosal, Neomycin or Gentamicin)
Have you ever had a serious reaction or fainted after receiving any vaccinations?
Have you received any vaccinations in the past 4 weeks?
Do you have cancer, leukemia, HIV, shingles or any other immune system problems?
Do you take prednisone, oral steroids, anticancer drugs, antiviral medications, or medications that affect the immune system?
During the past year, have you received a transfusion of blood or blood products, been given a medicine called immune (gamma) globulin or had radiation therapy?
CONSENT AND RELEASE
I acknowledge that I have received and understand the benefits and risks associated with the requested vaccine(s), as described in the Vaccine Information Statements (VIS) provided through the links next to each vaccine. VIS documents are also available on the Paris Apothecary website, or I may request a paper copy of each VIS at the pharmacy.
I confirm that Paris Apothecary has answered all of my questions regarding the vaccine(s) and the vaccination procedure to my satisfaction.
I voluntarily request and consent to the administration of the vaccine(s) to myself or to the person named above. If the person being vaccinated is a minor, I represent and warrant that I am the parent, legal guardian, or otherwise authorized representative with authority to provide this consent.
I authorize Paris Apothecary to release any medical or other information necessary to my physician, Medicare, insurance company, or applicable immunization registry for purposes of processing insurance claims and documenting the administration of the vaccine(s).
I, for myself, my heirs, and my executors, hereby release Paris Apothecary from any and all claims arising out of or in connection with the quality of the vaccine(s) as provided by the manufacturer or with any negligence by Paris Apothecary related to the administration of the vaccine(s), to the extent permitted by applicable law.
I understand that the laws of my state may affect my rights and remedies in connection with this vaccination.
I have read and understand the Vaccination Consent and Release Form and acknowledge that my electronic signature constitutes my consent to the vaccination(s) requested.