Costco Pharmacy Immunization Consent Form at a glance
What it is: The Costco Pharmacy Immunization Consent Form, PHA000021B 1025, is the form for requesting that the immunization(s) be given to me or my Ward.
Who signs: Sign on the SIGNATURE/LEGAL GUARDIAN line and write the PRINT NAME.
You sign to request that the immunization(s) be given to you or, as the legal guardian, to your Ward.
A filled-in Costco Pharmacy Immunization Consent Form example: an adult requests an influenza injectable vaccine
How to fill out Costco Pharmacy Immunization Consent Form, box by box
Patient Information
Under PATIENT INFORMATION, enter the patient's last name, first name, MI, gender (M/F), birth date (MM/DD/YYYY) and age.
Enter the address, city, state, zip and 10-digit mobile phone number.
Enter the primary care provider (MD, DO, NP, PA), the provider phone/fax and the primary care provider address.
Race and Ethnicity
Under RACE, check all that apply: American Indian or Alaska Native, Asian, Black or African American, Caucasian, Native Hawaiian or Other Pacific Islander, or Other, and write it on the line.
Under ETHNICITY, check one: Hispanic or Latino, or Not Hispanic or Latino.
Insurance Information
Under INSURANCE INFORMATION, check UNINSURED, CASH, MEDICARE # or OTHER INSURANCE CARRIER NAME, and enter the GROUP #, BIN/PCN: and ID #.
Vaccine(s) Requested
Under VACCINE(S) REQUESTED, check the vaccine: Influenza injectable, Influenza nasal, Pneumococcal, Meningococcal, Hepatitis A, Hepatitis B, Hepatitis A & B, HPV, Polio, Varicella (Chickenpox), Zoster (Shingles), Tetanus (Td), Whooping Cough (Tdap, DTaP), Measles Mumps & Rubella (MMR), COVID (indicate Brand) or Other.
Precautions and Contraindications
Under PRECAUTIONS AND CONTRAINDICATIONS, check yes or no for each question.
1. Are you sick today? (Yes or No)
2. Do you have allergies to medications, food or vaccines? Write the Allergies on the line. (Yes or No)
3. Have you ever had a serious reaction after receiving an immunization? (Yes or No)
4. Have you ever fainted or felt dizzy after receiving an immunization? (Yes or No)
5. Are you currently being treated for a long-term health problem such as heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder? (Yes or No)
6. Are you currently being treated for cancer, leukemia, AIDS or any other immune system problem? (Yes or No)
7. Are you currently taking cortisone, prednisone, other steroids or anti-cancer drugs, or have you had X-ray treatments? (Yes or No)
8. Do you have a history of Guillain-Barre Syndrome? (Yes or No)
9. Have you had a seizure, brain or nerve problem? (Yes or No)
10. During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin? (Yes or No)
11. For women: Are you pregnant or is there a chance you could become pregnant during the next month? (Yes or No)
12. Have you received any vaccinations in the past 4 weeks? If yes, what vaccines? (Yes or No)
13. Are you allergic to eggs? (Yes or No)
14. Are you allergic to latex? (Yes or No)
15. For tetanus: do you have a cut, injury, puncture or open wound? (Yes or No)
Adverse Reactions and Signature
Under ADVERSE REACTIONS, 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.
Sign on the SIGNATURE/LEGAL GUARDIAN line and write the PRINT NAME.
More rules for Costco Pharmacy Immunization Consent Form
The ADMINISTRATIVE RECORD is for pharmacy use only.
Provide a copy of this form to your physician and/or healthcare provider for your permanent medical records. WHITE is Administrative Copy; YELLOW is Patient Copy.
Sources
[1] Costco Pharmacy Immunization Consent Form (PHA000021B), Costco (the Official source link on this page).
