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392 E Lennon Drive P 903-953-1392
Mon-Fri: 8a-6p Sat: 9a-1p Sun: closed

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Rains Pharmacy Vaccine Consent Form

First name

Last name

Birthdate

Employer/Campus

Are you 65 or older? *

Yes, I'm 65 or older today

No, I'm younger than 65 today

Sex *

Male

Female

Street Address

City

Region/State/Province

Postal / Zip code

Cell Phone Number

Primary Care Doctor Name

Vaccine Requested * Required

Flu

B12

COVID-19 (MODERNA)

RSV

Insurance Coverage * Required

Insurance

Self Pay (FLU $25,B12 $15)

Are you feeling sick today? *

Yes

I don't know

Do you have any allergies to any medications, food (egg products), or vaccines? *

Yes

I don't know

Have yo ever fainted or had a serious reaction to a vaccine? *

Yes

I don't know

Are you pregnant or likely to become pregnant in the next 3 months? *

Yes

I don't know

Do you have cancer, AIDS, or any other immune system problems? *

Yes

I don't know

Do you currently take any oral steroids, anti-cancer meds, radiation, or immune suppressing medicatinons? *

Yes

I don't know

In the last year, have you received a blood transfusion, plasma, or immunoglobulin? *

Yes

I don't know

Do you havea brain disorder or suffer from seizures? *

Yes

I don't know

Have you received any vaccinations in the last 4 weeks? *

Yes

I don't know

Have you received TB skin test in the last week? *

Yes

I don't know

Date

Authorization to Administer: I have read or have had explained to me in written information about the vaccine. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and the risks of the vaccine(s) and I hereby authorize the person for whom I authorized to make medical decisions. Your signature:

I accept terms & conditions

Successful! See you there!

Contact Us

Rains Pharmacy

392 E Lennon Drive

Emory, Texas 75440

Tel 903-953-1392

Fax 903-953-1393

rainspharmacy@yahoo.com

Facebook: rainspharmacy

Website: rainspharmacy.com

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392 E Lennon Drive P 903-953-1392 Mon-Fri: 8a-6p Sat: 9a-1p Sun: closed

Rains Pharmacy Vaccine Consent Form

Contact Us

Rains Pharmacy

392 E Lennon Drive P 903-953-1392
Mon-Fri: 8a-6p Sat: 9a-1p Sun: closed