Med-Save Martin

Prior to your immunization appointment, please complete this immunization consent form and screening. If you have any questions, please contact us at 606-949-1349. Thank you!

Patient Information

Name * Birthdate * Street Address * City * State * Zip Code * 10-digit Phone Number * Email address

Insurance/Payment Information

Type * Insurance Plan Name * Member ID # * Rx BIN # Rx PCN # Rx Group # Medicare ID # (Red, White, & Blue Card)

Precautions and Contraindications

Have you ever had an allergic reaction to a vaccine or an injectable medication? * Do you have any allergies to oral medications, food, pet, or environmental? * If yes, please list the allergy and what reaction occured Have you received any vaccinations in the past 4 weeks? * If yes, please list the vaccine and date received Do you have a weakened immune system caused by a disease or do you take immunosuppressive drugs or therapies? * Do you take blood thinners or have a bleeding disorder? * Are you pregnant or breastfeeding? * Are you allergic to eggs? * Are you allergic to latex? *

COVID-19 Vaccine Questions

In the past 14 days, have you had a fever or been exposed to COVID-19? * Have you ever tested positive for COVID-19? Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? Have you ever received a dose of COVID-19 vaccine? When did you receive the COVID-19 vaccine dose? Which COVID-19 vaccine are you wanting to receive? *

Adverse Reactions

A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of any vaccine causing serious harm, or death, is extremely small. Local symptoms may include: slight tenderness, itching, or swelling at the site of injection. Systemic symptoms may include: fever, malaise, and muscle pain. Other systemic symptoms may occur infrequently. These reactions usually begin 6 to 12 hours after immunization and can persist for a few days. Immediate presumable allergic reactions such as hives, angioedema, allergic asthma, or systemic anaphylaxis occur rarely after immunization. These reactions may result from hypersensitive reactions in people with severe egg allergy, and such people should not be given certain vaccines that contain eggs. People with documented immunoglobulin E (IgE)-mediated hypersensitivities to eggs or or any other vaccine components, including thimerosal, may also be at increased risk of reactions from immunizations. In the case of a severe reaction such as a high fever, behavioral changes or flu-like symptoms that occur after vaccination, see a doctor right away. Signs of an allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat, or dizziness within a few minutes to a few hours after the shot.

Patient Consent

I understand the benefits and the risks of the vaccination as described in the Emergency Use Authorization (EUA) and/or CDC Vaccine Information Statement (VIS), a copy of which was provided with this Consent and am authorized to sign this Consent and Release.

I Consent * Signature * Today's Date *

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the Pharmacy and my rights with respect to my health information, including reporting to the State Vaccination Registry and/or local or state Departments of Heath, federal Department of Health and Human Services, and the Center for Disease Control and Prevention.

I Consent * Signature * Today's Date * Would you like to transfer your prescriptions to this pharmacy? *