Vaccine Order Verification

Use of this site and material contained on its pages is for EDUCATIONAL USE ONLY.

Pharmskills Online - Vaccine Order Verification - View Details

Pharmacist Verification
Select Pharmacist Action:

Click the Buttons to View

Patient Consent Form

1. Patient Information
Last Name:		First Name:
Date of Birth:		Age:
Gender:		Phone Number:
Street Address:
Chronic Illness:
Allergies:
Primary Care Provider (PCP):
PCP Address:		PCP Phone Number:
I want to receive the following vaccines:
Note for Pharmacist:

2. Insurance Information
Insurance Provider:		Member ID / Policy #:
Member Name:		Person Code:
RX BIN:		RX PCN:
Group ID:		Group Number:

3. Screening Questions		Yes / No
Are you currently sick or experiencing a high fever today?
Do you have severe allergies to medications, foods (e.g., eggs), or latex?
Have you ever had a serious reaction to a previous vaccine, including dizziness/fainting?
Do you have a bleeding disorder or are you taking blood thinners?
Are you immunocompromised (e.g., cancer, HIV, steroid medications)?
For women: Are you currently pregnant or breastfeeding?

4. Consent & Signature
I have read the information regarding the vaccine. I have had the opportunity to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine and ask that the vaccine be given to me or to the person named above for whom I am authorized to make this request.
Patient/Guardian Signature:	Robert Elder
Date:

5. For Office Use Only
Vaccine:		NDC Number:
Vaccine Manufacturer:
Dose:		Injection Site:
Vaccine Lot Number:		Vaccine Expiration Date:
Date on VIS:		Date VIS given:
Administrator Name:		Date Administered: