Georgies Pharmacy - Vaccine Consent Form

Appointment & Location

📅 Appointment or Walk-in?

Yes, I'll make an appointment No, I'm at the pharmacy now as a walk-in

📍 Select Pharmacy Location

Patient Information

Patient Full Name

Date of Birth

Gender

Male Female Other Prefer not to say

Vaccine Selection

Which vaccine(s) do you want to get? (Select all that apply)

Select one or more vaccines. Multiple vaccines can be administered in the same visit.

📞 Looking for a different vaccine?

Call us to check availability:
• Family: (908) 925-4567
• Parlin: (732) 952-3022
• Outpatient: (609) 726-5800
• Specialty: (908) 925-4566

Contact Information

Phone Number

Email Address

We'll send you confirmation and vaccine records

Street Address

Apartment, Suite, etc. (Optional)

City

State

ZIP Code

Insurance

Insurance Status

I have insurance I do not have insurance I'm not sure

Parental / Guardian Consent

Since the patient is under 18, we require parental or guardian consent.

Parent/Guardian Full Name

Relationship to Patient

Parent/Guardian Phone

I have been counseled about potential side effects and the importance of well-child visits with a pediatrician

Screening Questions

Please answer these questions to ensure safe vaccination:

Do you currently have a fever (temperature over 100.4°F)?

Yes No

Do you have any allergies to vaccines or their components?

Yes No

Have you ever had a serious reaction to a vaccine?

Yes No

Have you received any vaccines in the past 30 days?

Yes No

Are you pregnant, breastfeeding, or planning to become pregnant?

Yes No N/A

Signature & Consent

Type your full name to sign

Your signature will appear here

I certify all information is accurate, have been offered Vaccine Information Statements, and consent to vaccination *

Vaccine Information Statements (VIS)

Review the VIS documents for your selected vaccines:

🏥 Georgies Pharmacy

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Appointment & Location

Patient Information

CHRONIC DISEASES:

IMMUNE SYSTEM CONDITIONS:

LIFESTYLE FACTORS:

OCCUPATION & EXPOSURE:

PREGNANCY & REPRODUCTIVE HEALTH:

Vaccine Selection

RECOMMENDED VACCINES FOR YOUR AGE ( years old)

Contact Information

Insurance

Parental / Guardian Consent

Screening Questions

Signature & Consent

Vaccine Information Statements (VIS)