Vaccine Administration Record & Informed Consent

Olympia Plaza Pharmacy · 5901 W. Olympic Blvd, Ste 103, Los Angeles, CA 90036 · (323) 937-2590

Fields marked * are required. One form per patient.

  1. 1 Consent & screening
  2. 2 Insurance & ID
Vaccine(s) patient wants

Select at least one.

A $150 fee will be charged for international vaccination certificates of immunization replacements.

Please select at least one vaccine.

Section A Patient information
Gender

Please select one.

Race (select all that apply)

Please select at least one (or "Unknown").

Ethnicity

Please select one.

Section B Screening questions

These questions help us determine your eligibility to be vaccinated. Every question must be answered — choose “Don’t know” if you are unsure. Extra questions appear based on the vaccines you selected.

  1. Do you feel sick today?

    Please choose Yes, No or Don’t know.

  2. Have you been diagnosed with or tested positive for COVID-19 in the last 14 days?

    Please choose Yes, No or Don’t know.

  3. In the past 14 days have you been identified as a close contact to someone with COVID-19?

    Please choose Yes, No or Don’t know.

  4. Do you have a history of allergic reaction or allergies to latex, medications, food or vaccines (examples: polyethylene glycol, polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?

    Please choose Yes, No or Don’t know.

  5. Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?

    Please choose Yes, No or Don’t know.

  6. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?

    Please choose Yes, No or Don’t know.

  7. Have you received any vaccinations or skin tests in the past eight weeks?

    Please choose Yes, No or Don’t know.

  8. Have you ever received the following vaccinations?

    Pneumonia

    Please answer.

    Shingles

    Please answer.

    Whooping cough

    Please answer.

  9. Do you have any chronic health condition such as cancer, chronic kidney disease, immunocompromised, chronic lung disease, obesity, sickle cell disease, diabetes, heart disease?

    Please choose Yes, No or Don’t know.

  10. For women: Are you pregnant or considering becoming pregnant in the next month?

    Please choose Yes, No or Don’t know.

  11. For COVID-19 vaccine only: Have you been treated with antibody therapy specifically for COVID-19 (monoclonal antibodies or convalescent plasma)?

    Please choose Yes, No or Don’t know.

  12. Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS, transplant)?

    Please choose Yes, No or Don’t know.

  13. Are you currently on home infusions, weekly injections such as Humira® (adalimumab), Remicade® (infliximab) or Enbrel® (etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?

    Please choose Yes, No or Don’t know.

  14. Are you currently taking high-dose steroid therapy (prednisone > 20mg/day or equivalent) for longer than 2 weeks?

    Please choose Yes, No or Don’t know.

  15. Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in the past year?

    Please choose Yes, No or Don’t know.

  16. Do you have a history of thymus disease (including myasthenia gravis, DiGeorge syndrome or thymoma), or had your thymus removed? (yellow fever only)

    Please choose Yes, No or Don’t know.

  17. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)

    Please choose Yes, No or Don’t know.

  18. Have you consumed any food or drink in the last hour? (Vaxchora® / cholera only)

    Please choose Yes, No or Don’t know.

  19. Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days? (Vaxchora® / cholera only)

    Please choose Yes, No or Don’t know.

  20. Please list the countries you are traveling to.

Section C Informed consent & signature

I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where the patient is not otherwise competent or unable to consent for themselves. Further, I hereby give my consent to Olympia Plaza Pharmacy, Inc and the licensed healthcare professional administering the vaccine, as applicable (each an “applicable Provider”), to administer the vaccine(s) I have requested above. I understand that people aged 60 years or older, due to a higher risk of life-threatening side effects, Yellow Fever vaccines should be given only when there is a significant and unavoidable risk of acquiring yellow fever infection, such as travel to an area where there is a current or periodic risk of yellow fever transmission. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Fact Sheet on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised that the patient should remain near the vaccination location for observation for approximately 15 minutes after administration. On behalf of the patient, the patient’s heirs and personal representatives, I hereby release and hold harmless each applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that: (a) I understand the purposes/benefits of my state’s vaccination registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, or to any state or federal governmental agencies or authorities (“Government Agencies”), such as state, county, or local Departments of Health or the federal Department of Health and Human Services, the Centers for Disease Control and Prevention, or their respective designees as may be required by law, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I acknowledge that, depending upon my state’s law, I may prevent, by using a state-approved opt-out form or, as permitted by my state law, an opt-out form (“Opt-Out Form”) furnished by the applicable Provider: (a) the disclosure of my vaccination information by the applicable Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my vaccination information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The applicable Provider will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically consent, and, to the extent required by my state’s law, by signing below, I hereby do consent to the applicable Provider reporting my vaccination information to the Government Agencies, State HIE, or through the State HIE and/or State Registry to the entities and for the purposes described in this Informed Consent form. Unless I provide the applicable Provider with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the applicable Provider and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws or federal law may permit certain disclosures of my vaccination information to or through the State HIE or to Government Agencies as required or permitted by law. I further authorize the applicable Provider to: (a) release my medical or other information, including any communicable disease (including HIV) and mental health information, to, or through, the State HIE or Government Agencies to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment; (b) submit a claim to my insurer for the above requested items and services; and (c) request payment of authorized benefits be made on my behalf to the applicable Provider with respect to the above requested items and services. I further agree to be fully financially responsible for any cost-sharing amounts, including copays, coinsurance and deductibles, for the requested items and services, as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, if the applicable Provider invoices me after the time of service, upon receipt of such invoice. Olympia Plaza Pharmacy, Inc or its affiliates may contact you, including by autodialed and prerecorded calls and texts, at any time, using the contact information provided in your patient record regarding health and safety matters, such as vaccine reminders.

You must agree to the consent to continue.

The patient is under 18 — a parent or legal guardian must sign.

Patient signature (parent or guardian, if minor)
✕

By signing, you agree that your electronic signature is the legal equivalent of your handwritten signature. Date:

Please sign (draw or type your signature).

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