Immunization Consent Form Which vaccine(s) are you interested in?(required) Flu Shingles Pneumonia Covid-19 Click to view Vaccine Information Statement for flu Click to view Vaccine Information Statement for shingles (Shingrix) Click to view Vaccine Information Statement for pneumonia (Prevnar) Click to view Vaccine Information Statement for pneumonia (Pneumovax) Click to view Emergency Use Authorization Facts for Covid-19 First Name(required) Last Name(required) Date of Birth (MM/DD/YY)(required) Address(required) Phone Number (required) Preferred Method of Contact(required) Call Text Primary Care Physician Primary Care Physician's phone number Emergency Contact Emergency Contact's Phone Number Have you had a physical examination within the past year?(required) Yes No Unsure If yes, when? Are you sick today?(required) Yes No Unsure Do you have a fever or acute illness?(required) Yes No Unsure Do you have allergies to medications, eggs or other food, a vaccine component, latex, or Thimerosal?(required) Yes No Unsure If yes, list allergies Have you ever had a serious reaction after receiving a vaccination?(required) Yes No Unsure Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder?(required) Yes No Unsure If yes, please explain What medications are you currently taking? Do you have cancer, leukemia, HIV/AIDS or any other immune system problem?(required) Yes No Unsure Have you had a seizure, brain disorder, Guillain-Barre Syndrome or other nerve problem?(required) Yes No Unsure I CERTIFY THAT I AM: (A) THE PATIENT AND AT LEAST 18 YEARS OF AGE; OR (B) THE PARENT OR LEGAL GUARDIAN OF THE PATIENT ('WARD'). I HAVE BEEN PROVIDED A COPY OF THE APPLICABLE VACCINE INFORMATION STATEMENT(S) OR EMERGENCY USE AUTHORIZATION FACT SHEET(S) AND I HAVE READ THE ADVERSE REACTIONS ASSOCIATED WITH THE ADMINISTRATION OF THE VACCINE(S). FURTHERMORE, I CONSENT TO THE ADMINISTRATION OF THE VACCINE(S) REQUESTED ABOVE TO ME OR MY WARD AND ACKNOWLEDGE THAT, AS A CONDITION TO ADMINISTRATION OF THE VACCINE(S), MYSELF OR MY WARD MUST REMAIN UNDER THE OBSERVATION OF THE ADMINISTERING PHARMACIST FOR A PERIOD OF NOT LESS THAN 15 MINUTES. I UNDERSTAND THAT A COPY OF THE VACCINE MANUFACTURER'S DRUG INFORMATION SHEET IS AVAILABLE ON REQUEST. FURTHERMORE, I ALSO HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THE IMMUNIZATION(S). I BELIEVE THE BENEFITS OUTWEIGH THE RISKS AND I VOLUNTARILY ASSUME FULL RESPONSIBILITY OF ANY REACTIONS THAT MAY RESULT FROM EITHER MY RECEIPT OF THE IMMUNIZATION(S) OR THE RECEIPT OF THE IMMUNIZATION(S) BY THE NAMED ABOVE FOR WHOM I AM THE WARD. MY MEDICAL RECORD, MAY BE SHARED WITH MY PRIMARY CARE PROVIDER OR OTHER HEALTHCARE PROVIDER AND THE MEDICAL RECORD OF MY WARD MAY BE SHARED WITH HIS/HER PRIMARY CARE PROVIDER OR OTHER HEALTHCARE PROVIDER. I, FOR MYSELF AND ON BEHALF OF MY WARD, AND EACH OF OUR RESPECTIVE HEIRS, EXECUTORS, PERSONAL REPRESENTATIVES AND ASSIGNS, HEARBY RELEASE LULA PHARMACY, AND ITS AFFILIATES, SUBSIDIARIES, DIVISIONS, DIRECTORS, CONTRACTORS, AGENTS AND EMPLOYEES (COLLECTIVELY "RELEASED PARTIES") FROM ANY AND ALL CLAIMS ARISING OUT OF, IN CONNECTION WITH OR IN ANY WAY RELATED TO MY RECEIPT AND THE RECEIPT BY MY WARD OF THIS OR THESE IMMUNIZATION(S). NEITHER LULA PHARMACY NOR ANY OF THE RELEASED PARTIES SHALL, AT ANY TIME OR TO ANY EXTENT WHATSOEVER, BE LIABLE, RESPONSIBLE OR IN ANY WAY ACCOUNTABLE FOR ANY LOSS, INJURY, DEATH OR DAMAGE SUFFERED OR SUSTAINED BY ANY PERSON AT ANY TIME IN CONNECTION WITH OR AS A RESULT OF THIS VACCINE PROGRAM OR THE ADMINISTRATION OF THE VACCINE(S) DESCRIBED ABOVE. I AUTHORIZE LULA PHARMACY TO (A) NOTIFY MY OR MY WARD'S PRIMARY CARE PROVIDER OF THE VACCINE(S) ADMINISTERED AND TO PROVIDE SAME WITH COPIES OF ALL VACCINATION RECORDS; (B) TO ENTER MY OR MY WARD'S VACCINE INFORMATION ON THE GEORGIA REGISTRY OF IMMUNIZATION TRANSACTIONS; AND (C) MAKE ANY OTHER DISCLOSURES REQUIRED BY LAW. LULA PHARMCY WILL USE AND DISCLOSE YOUR PERSONAL AND HEALTH INFORMATION OR THE PERSONAL AND HEALTH INFORMATION OF YOUR WARD, TO RECEIVE PAYMENT OF THE CARE WE PROVIDE, AND FOR OTHER HEALTH CARE OPERATIONS. HEALTHCARE OPERATIONS GENERALLY INCLUDE THOSE ACTIVITIES PERFORMED TO IMPROVE QUALITY OF CARE. I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES(required) By checking this box, I acknowledge that I have read and understand, and agree to the above Today's date(required) Submit Δ
