Costco Immunization Form PDF Details

In today’s health-conscious world, staying up to date with immunizations is more important than ever, and Costco’s Immunization Consent Form plays a pivotal role in this preventative health measure. Designed with the patient's safety and health in mind, this comprehensive form captures essential personal and health information, including the patient's name, gender, contact details, Medicare ID, and primary healthcare prescriber’s details. It thoroughly screens for possible contraindications to vaccination through a detailed questionnaire asking about current health status, allergies, previous adverse reactions to vaccines, chronic health conditions, pregnancy status, and recent vaccine history. Furthermore, the form outlines potential adverse reactions to vaccines, emphasizing the rarity but seriousness of such outcomes, thereby ensuring patients are well-informed before making a decision. It also includes sections for pharmacy use, such as vaccine administration records and payment information, emphasizing the procedural aspects of immunization. By signing the form, patients, or their legal guardians, consent to the vaccination while acknowledging the potential risks and benefits, indicating an informed and voluntary decision. Importantly, the form encapsulates Costco’s commitment to patient privacy and the careful handling of personal and health information, conforming to healthcare operation standards outlined in the Notice of Privacy Practices. This form not only facilitates a smooth immunization process but also exemplifies the necessary precautions and legal responsibilities assumed by both the patient and the provider.

QuestionAnswer
Form NameCostco Immunization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescostco pharmacy flu shot form, costco flu shot, costco flu shot booking, is costco giving shots now

Form Preview Example

IMMUNIZATION CONSENT FORM

PATIENT’S LAST NAME

PATIENT’S FIRST NAME

MI

GENDER (M/F)

 

 

 

 

 

 

ADDRESS

CITY

 

STATE

ZIP

 

 

 

 

10-DIGIT PHONE NUMBER

MEDICARE ID NUMBER

 

BIRTH DATE (MM/DD/YYYY)

 

 

 

 

PRIMARY HEALTHCARE PRESCRIBER

PRESCRIBER ADDRESS

PRESCRIBER PHONE/FAX

VACCINE REQUESTED

PRECAUTIONS AND CONTRAINDICATIONS (Please check yes or no for each question.)

1.

Are you sick today?

r Yes r No

2.

Do you have allergies to medications, food or vaccines?

r Yes r No

 

Allergies ___________________________________________________________

3.

Have you ever had a serious reaction after receiving a vaccination?

r Yes r No

4.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?

r Yes r No

5.Do you have cancer, leukemia, AIDS or any other immune system problem? r Yes r No

6.Do you take cortisone, prednisone, other steroids or anti-cancer drugs,

or have you had X-ray treatments?

r Yes r No

7. Have you had a seizure, brain or nerve problem?

r Yes r No

8.During the past year, have you received a transfusion of blood or blood products, or been given a medicine called

immune (gamma) globulin?

r Yes r No

9. For women: Are you pregnant or is there a chance you could

 

become pregnant during the next month?

r Yes r No

10.Have you received any vaccinations in the past 4 weeks?

r Yes r No

If yes, what vaccines? _________________________________________________

11.Are you allergic to eggs?

r Yes r No

12.Are you allergic to latex?

r Yes r No

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, redness, 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 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, behavior 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.

 

 

 

ADMINISTRATIVE RECORD

FOR PHARMACY USE ONLY

 

VACCINE: __________________

EXPIRATION DATE: _________

 

VACCINE: __________________

EXPIRATION DATE: _________

 

VACCINE: __________________

EXPIRATION DATE: _________

 

 

VIS VERSION:________________

SITE OF INJECTION: ________

 

VIS VERSION:________________

SITE OF INJECTION: ________

 

VIS VERSION:________________

SITE OF INJECTION: ________

MANUFACTURER: ____________

DOSAGE: ________________

 

MANUFACTURER: ____________

DOSAGE: ________________

 

MANUFACTURER: ____________

DOSAGE: ________________

LOT NUMBER: _______________

ROUTE OF ADMIN: _________

 

LOT NUMBER: _______________

ROUTE OF ADMIN: _________

 

LOT NUMBER: _______________

ROUTE OF ADMIN: _________

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT INFORMATION

FOR PHARMACY USE ONLY

 

 

 

 

 

 

 

 

 

 

VACCINE FEES

 

 

TOTAL CHARGE

 

 

 

 

 

“I have read the adverse reactions associated with the administration of vaccines. A copy of the vaccine manufacturer’s drug information sheet is available on request. Furthermore, I have also had an opportunity to ask questions about these immunizations. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization(s) or the receipt of the immunization(s) by the person named below for whom I am the legal guardian (‘Ward’). My medical record may be shared with my physician or other healthcare provider and the medical record of my Ward may be shared with his/her physician or other healthcare provider. I am requesting that the immunization(s) be given to me or my Ward. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release Costco, 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 Costco nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable, responsible or 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 vaccines described above. Costco will use and disclose your personal and health information or the personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies in regard to you and your Ward’s personal health information. I acknowledge that I have received a copy of the Notice of Privacy Practices.”

 

 

 

 

 

 

SIGNATURE/LEGAL GUARDIAN

 

DATE OF VACCINATION/DATE VIS GIVEN

 

 

 

 

 

 

 

 

 

PRINT NAME

 

PHARMACIST/PRESCRIBER SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

PHARMACY NAME/ADDRESS

 

 

 

 

 

 

 

 

 

PLEASE PROVIDE A COPY OF THIS FORM TO YOUR PHYSICIAN AND/OR HEALTHCARE PROVIDER FOR YOUR PERMANENT MEDICAL RECORDS.

 

 

 

WHITE – ADMINISTRATIVE COPY

YELLOW – PATIENT COPY

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You should write down the required data in the ADMINISTRATIVE RECORD FOR PHARMACY, VACCINE EXPIRATION DATE, VACCINE EXPIRATION DATE, VACCINE EXPIRATION DATE, VIS VERSION SITE OF INJECTION, VIS VERSION SITE OF INJECTION, VIS VERSION SITE OF INJECTION, MANUFACTURER DOSAGE, MANUFACTURER DOSAGE, MANUFACTURER DOSAGE, LOT NUMBER ROUTE OF ADMIN, LOT NUMBER ROUTE OF ADMIN, LOT NUMBER ROUTE OF ADMIN, PAYMENT INFORMATION FOR PHARMACY, and VACCINE FEES field.

costco pharmacy flu shot form ADMINISTRATIVE RECORD FOR PHARMACY, VACCINE  EXPIRATION DATE, VACCINE  EXPIRATION DATE, VACCINE  EXPIRATION DATE, VIS VERSION  SITE OF INJECTION, VIS VERSION  SITE OF INJECTION, VIS VERSION  SITE OF INJECTION, MANUFACTURER  DOSAGE, MANUFACTURER  DOSAGE, MANUFACTURER  DOSAGE, LOT NUMBER  ROUTE OF ADMIN, LOT NUMBER  ROUTE OF ADMIN, LOT NUMBER  ROUTE OF ADMIN, PAYMENT INFORMATION FOR PHARMACY, and VACCINE FEES blanks to complete

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