Georgies Pharmacy Vaccine Consent Form
Better Care. Better Health.
Where would you like to get the vaccine?
Select Location
Georgies Family Pharmacy
Georgies Outpatient Pharmacy
Georgies Parlin Pharmacy
Georgies Specialty Pharmacy
Which vaccination do you want to get?
Select
Influenza
COVID-19
Pneumonia
RSV
Other
If Other, please specify:
Would you like an appointment? (Walk-ins are welcome)
Select
Yes
No
Appointment Date
Appointment Time
Patient Name
Date of Birth
Phone Number
Email
Address
Gender
Select
Male
Female
Other
Ethnicity
Select
Hispanic Origin
Non-Hispanic Origin
Unknown
Race
Select
African American or Black
Asian
Decline to answer
Native American or Alaskan
Native Hawaiian or Pacific Islander
Other or Multiracial
White
Primary Doctor Name
Current Pharmacy
Insurance Status
Select
Insured
Uninsured
Insurance Type
Select
Medicare
Medical Insurance
Pharmacy Insurance
Screening for Immunization
Fever or illness today?
No
Yes
Allergy to eggs, latex, or component?
No
Yes
Serious reaction in the past?
No
Yes
Guillain-Barre syndrome or neurological disorder?
No
Yes
Received vaccines in the past 30 days?
No
Yes
Pregnant, breastfeeding, or planning to be?
No
Yes
Consent for Immunization
Date
Signature (Type Name)
Submit