A New Species of Agathoxylon Hartig From the Sriperumbudur formation, Tamil Nadu, India
Consent for Vaccination - Hartig Drug...Aug 03, 2020 · Unless I provide Hartig Drug with a signed...
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White – Pharmacy Copy Yellow – Patient Copy Revised date: 9/11/2013 Consent for Vaccination Section A Please print clearly LAST NAME FIRST NAME MI GENDER (M/F) ADDRESS CITY STATE ZIP ( ) / / PHONE NUMBER MEDICARE B # (IF APPLICABLE) DATE OF BIRTH AGE ( ) PRIMARY CARE PHYSICIAN/PROVIDER NAME PHYSICIAN/PROVIDER ADDRESS PHYSICIAN/PROVIDER PHONE Section B Please answer the following question to determine if you are eligible to receive a vaccination today 1. Which vaccine are you requesting to have administered today? Please check all requested vaccine(s). Don’t Flu (Influenza) Pneumonia (Pneumococcal) Shingles (Zoster) Whooping Cough (Tdap) Other: _____________________ Yes No Know 2. Do you feel sick today? 3. Have you had any of the following symptoms the past 14 days: Cough, Muscle pain, Fever (Temp > 100.4F), unexpected shortness of breath, chills, or sore throat? 4. Have you been in contact with anyone with confirmed or suspected coronavirus (COVID-19) infection within the past 14 days? 5. Do you have allergies to medications, food, or vaccines? (Example: eggs, gelatin, gentamicin, polymyxin, neomycin, phenol, thimerosal or latex) If yes, please list the allergies:_________________________________________________________________________________ 6. Have you received any vaccinations or skin tests in the past four weeks? If yes, please list the vaccination/skin test:___________________ 7. Have you ever had a serious reaction to any vaccine in the past? 8. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome, or other nervous system problems? 9. Are you 65 years of age or older? 10. Do you smoke? 11. Do you have a chronic condition or long-term health problem? If yes, please check all that apply: Anemia Asthma Diabetes Heart Disease Liver Disease Lung Disease Other:_____________________________ 12. If you answered yes to question #7, 8 or 9, have you ever had a pneumonia vaccination? 13. Have you ever had a shingles vaccination (for patients 50 years of age and older only)? 14. For women: Are you pregnant or considering becoming pregnant in the next month? 15. Are you currently on a blood thinning medication such as warfarin or aspirin therapy? For Live Vaccine ( Chicken Pox, Nasal flu, etc): 16. Are you currently on home infusions, weekly injections, steroid therapy, anticancer drugs, or radiation treatment? 17. Do you have cancer, leukemia, lymphoma, HIV/AIDS, or any other immune system disorder or are you in contact with anyone who has a severely weakened immune system? 18. Have you received a transfusion of blood or blood products or have you been given a medicine called immune (gamma) globulin in the past year? Section C I certify that I am: (i) the patient and at least 18 years of age; (ii) the parent or legal guardian of the minor patient; or (iii) the legal guardian of the patient. Further, I hereby give my consent to the Hartig Drug immunization certified pharmacist, or intern (under the direct supervision of a pharmacist), to administer the vaccine(s) I have requested above. 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 to ask questions and that such questions were answered to my satisfaction. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering provider. On behalf of myself, my heirs and personal representative, I hereby release and hold harmless Hartig Drug, its staff, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I understand that my state may offer participation in a state immunization registry, in which case my immunization information may be supplied to the state unless I complete a state-approved opt-out process. Hartig Drug, will, if my state permits, provide me with an opt-out form. Unless I provide Hartig Drug with a signed opt-out form, I elect to participate fully in, and consent to Hartig Drug reporting my immunization information to the state’s immunization registry. I authorize Hartig Drug to (1) release my medical or other information to my healthcare professionals, Medicare, Medicaid, or other third-party payers as necessary to facilitate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf to Hartig Drug with respect to the above requested items and services. I further agree to be fully financially responsible for any due amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of services or if Hartig Drug invoices me after the time of service, upon receipt of such invoice. Patient/Legal Representative Signature:______________________________________________________________________ Date:__________________________ FOR PHARMACY USE ONLY Vaccine Lot# Exp Date Manufacturer Dosage Site VIS Date Immunizer Name (print):__________________________ Immunizer Signature:___________________________________________ Date:______________________ Entered into Immunization Registry on: ______________________ Primary Care Provider Notified on: ______________________
Transcript of Consent for Vaccination - Hartig Drug...Aug 03, 2020 · Unless I provide Hartig Drug with a signed...
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White – Pharmacy Copy Yellow – Patient Copy Revised date: 9/11/2013
Consent for Vaccination
Section A Please print clearly
LAST NAME FIRST NAME MI GENDER (M/F)
ADDRESS CITY STATE ZIP ( ) / /
PHONE NUMBER MEDICARE B # (IF APPLICABLE) DATE OF BIRTH AGE ( )
PRIMARY CARE PHYSICIAN/PROVIDER NAME PHYSICIAN/PROVIDER ADDRESS PHYSICIAN/PROVIDER PHONE
Section B Please answer the following question to determine if you are eligible to receive a vaccination today
1. Which vaccine are you requesting to have administered today? Please check all requested vaccine(s). Don’t Flu (Influenza) Pneumonia (Pneumococcal) Shingles (Zoster) Whooping Cough (Tdap) Other: _____________________ Yes No Know
2. Do you feel sick today? 3. Have you had any of the following symptoms the past 14 days: Cough, Muscle pain, Fever (Temp > 100.4F),
unexpected shortness of breath, chills, or sore throat? 4. Have you been in contact with anyone with confirmed or suspected coronavirus (COVID-19) infection within the past 14 days? 5. Do you have allergies to medications, food, or vaccines? (Example: eggs, gelatin, gentamicin, polymyxin, neomycin, phenol, thimerosal or latex) If yes, please list the allergies:_________________________________________________________________________________ 6. Have you received any vaccinations or skin tests in the past four weeks? If yes, please list the vaccination/skin test:___________________ 7. Have you ever had a serious reaction to any vaccine in the past? 8. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome, or other nervous
system problems? 9. Are you 65 years of age or older? 10. Do you smoke? 11. Do you have a chronic condition or long-term health problem? If yes, please check all that apply: Anemia Asthma Diabetes Heart Disease Liver Disease Lung Disease Other:_____________________________
12. If you answered yes to question #7, 8 or 9, have you ever had a pneumonia vaccination? 13. Have you ever had a shingles vaccination (for patients 50 years of age and older only)? 14. For women: Are you pregnant or considering becoming pregnant in the next month? 15. Are you currently on a blood thinning medication such as warfarin or aspirin therapy? For Live Vaccine ( Chicken Pox, Nasal flu, etc):
16. Are you currently on home infusions, weekly injections, steroid therapy, anticancer drugs, or radiation treatment? 17. Do you have cancer, leukemia, lymphoma, HIV/AIDS, or any other immune system disorder or are you in contact with anyone who has a
severely weakened immune system? 18. Have you received a transfusion of blood or blood products or have you been given a medicine called immune (gamma) globulin in the
past year?
Section C I certify that I am: (i) the patient and at least 18 years of age; (ii) the parent or legal guardian of the minor patient; or (iii) the legal guardian of the patient. Further, I hereby give my consent to the Hartig Drug immunization certified pharmacist, or intern (under the direct supervision of a pharmacist), to administer the vaccine(s) I have requested above. 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 to ask questions and that such questions were answered to my satisfaction. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering provider. On behalf of myself, my heirs and personal representative, I hereby release and hold harmless Hartig Drug, its staff, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I understand that my state may offer participation in a state immunization registry, in which case my immunization information may be supplied to the state unless I complete a state-approved opt-out process. Hartig Drug, will, if my state permits, provide me with an opt-out form. Unless I provide Hartig Drug with a signed opt-out form, I elect to participate fully in, and consent to Hartig Drug reporting my immunization information to the state’s immunization registry. I authorize Hartig Drug to (1) release my medical or other information to my healthcare professionals, Medicare, Medicaid, or other third-party payers as necessary to facilitate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf to Hartig Drug with respect to the above requested items and services. I further agree to be fully financially responsible for any due amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of services or if Hartig Drug invoices me after the time of service, upon receipt of such invoice.
Patient/Legal Representative Signature:______________________________________________________________________ Date:__________________________
FOR PHARMACY USE ONLY
Vaccine Lot# Exp Date Manufacturer Dosage Site VIS Date
Immunizer Name (print):__________________________ Immunizer Signature:___________________________________________ Date:______________________ Entered into Immunization Registry on: ______________________ Primary Care Provider Notified on: ______________________
LAST NAME: FIRST NAME: MI: GENDER MF: ADDRESS: CITY: STATE: ZIP: Flu Influenza: OffPneumonia Pneumococcal: OffShingles Zoster: OffWhooping Cough Tdap: Offundefined: OffOther: or latex If yes please list the allergies: 6 Have you received any vaccinations or skin tests in the past four weeks If yes please list the vaccinationskin test: 11 Do you have a chronic condition or longterm health problem If yes please check all that apply: OffAnemia: OffAsthma: OffDiabetes: OffHeart Disease: OffLiver Disease: OffLung Disease: OffOther_2: Date: PHONE NUMBER: DATE OF BIRTH: AGE: MEDICARE B #: Text6: Text7: Text8: Signature61_es_:signer:signature: Check Box60: OffCheck Box59: OffCheck Box58: OffCheck Box57: OffCheck Box55: OffCheck Box54: OffCheck Box53: OffCheck Box52: OffCheck Box51: OffCheck Box50: OffCheck Box49: OffCheck Box48: OffCheck Box47: OffCheck Box46: OffCheck Box45: OffCheck Box44: OffCheck Box43: OffCheck Box42: OffCheck Box41: OffCheck Box40: OffCheck Box39: OffCheck Box38: OffCheck Box37: OffCheck Box36: OffCheck Box35: OffCheck Box34: OffCheck Box33: OffCheck Box32: OffCheck Box31: OffCheck Box30: OffCheck Box29: OffCheck Box28: OffCheck Box27: OffCheck Box26: OffCheck Box25: OffCheck Box24: OffCheck Box23: OffCheck Box22: OffCheck Box21: OffCheck Box20: OffCheck Box19: OffCheck Box18: OffCheck Box17: OffCheck Box16: OffCheck Box15: OffCheck Box14: OffCheck Box13: OffCheck Box12: OffCheck Box11: OffCheck Box10: OffCheck Box9: Off
