The Costco Pharmacy Immunization Consent Form is a standardized one-page document required before any vaccine is given at a Costco pharmacy. It is also known as form PHA000021B and covers flu shots, COVID-19 vaccines, shingles shots, and other pharmacy vaccines. Understanding each section helps you complete it accurately and quickly at your next appointment.
The first section asks for your full legal name, date of birth, gender, home address, and phone number. You also need to provide the name of your primary healthcare prescriber. Medicare and Medicaid beneficiaries must include their Medicare ID number. Parents or legal guardians filling out the form for a minor must use their own contact information and will sign the consent section on behalf of the child.
Before any vaccine is given, the pharmacist uses this section to screen for possible contraindications. You answer yes or no questions about your current health. The questionnaire covers these topics:
If you answer yes to any screening question, the pharmacist reviews your answers before proceeding. In some cases, vaccination may be postponed or an alternative vaccine may be recommended. Answering these questions honestly protects your safety.
By signing the consent section, you confirm that you have read the Vaccine Information Statement provided by the pharmacist. This section summarizes potential adverse reactions, which range from mild injection site soreness to rare serious reactions occurring in fewer than 1 in 1,000,000 doses. Your signature indicates voluntary and informed consent. You may ask the pharmacist questions before signing at any time.
The lower portion of the form is completed by Costco pharmacy staff after the vaccine is given. Staff enter the vaccine manufacturer name, lot number, expiration date, site of injection (left or right arm, specific muscle), route of administration, dosage in milliliters, and the VIS version date. This record is submitted to your state immunization registry as required by state law. Do not attempt to fill in this section yourself.
All information you provide on the consent form is handled under the Health Insurance Portability and Accountability Act. Costco Pharmacy may share your vaccination records with your primary care provider and state immunization registries as part of routine healthcare operations. Full details appear in the Costco Pharmacy Notice of Privacy Practices, available at any pharmacy location or on the Costco website.
This single consent form applies to all vaccines offered by Costco Pharmacy at their in-store pharmacy locations across the United States. Covered vaccines include:
Vaccine availability varies by location and season. Call your local Costco pharmacy or check the pharmacy website to confirm which vaccines are currently offered at your preferred location.
After you submit the completed consent form at the pharmacy counter, the pharmacist reviews your screening answers. If there are no contraindications, you are taken to the immunization area, typically a private consultation room or partitioned area within the pharmacy. The pharmacist administers the vaccine and immediately completes the administrative record section of your form. You receive a copy of the Vaccine Information Statement and may be asked to wait 15 minutes after the shot so staff can monitor for any immediate reactions.
| Question | Answer |
|---|---|
| Form Name | Costco Immunization Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 5 min |
| Other names | costco pharmacy flu shot form, costco flu shot consent, costco immunization consent form, costco pharmacy vaccination form, PHA000021B |
