SHINGRIX Immunization Consent Form - Madison Pharmacy

Submit your completed SHINGRIX Immunization Consent Form through the following methods: Email: info@MadisonPharmacy.com, Fax: 573.377.1560, or by mailing it to the address: Madison Pharmacy, 66 S Main Street, Madison, NJ 17930. Ensure all required fields are filled, and your signature is included. For online submissions, save the filled-out and signed PDF and upload it through our online submission portal on www.MadisonPharmacy.com. Ensure you have a copy of the submitted form for your records. For questions, contact us at 573.377.0075. Our advice is to submit the form a few days prior to your vaccination appointment to avoid any delays.

This form is used whenever the SHINGRIX vaccine is administered. Please consult your healthcare provider for specific vaccination dates and schedules in 2024 and 2025.

The SHINGRIX Immunization Consent Form serves to collect essential patient information and ensure informed consent before administering the SHINGRIX vaccine. This detailed form includes fields for personal information, medical history, and current health status, which healthcare providers use to determine vaccine eligibility. By completing this form, patients acknowledge the potential risks of vaccination and provide legal consent for receiving the vaccine, ensuring both patient safety and compliance with medical standards. The form also allows for the sharing of medical records with physicians and insurance companies, facilitating coordinated care and accurate documentation. Ultimately, this consent form is a crucial component in the vaccination process, protecting both the patient and the healthcare provider from legal and medical liabilities. By signing the form, patients or their legal guardians provide informed consent, paving the way for safe and efficient administration of the SHINGRIX vaccine.

• 1. Patient Name: Full name of the patient receiving the vaccine.
• 2. Date of Birth: Patient's date of birth to confirm age.
• 3. Age: Current age of the patient.
• 4. Address: Home address of the patient.
• 5. City: City where the patient resides.
• 6. State: State where the patient resides.
• 7. Zip Code: Postal code for the patient's address.
• 8. Phone Number: Patient's contact number.
• 9. Primary Dr. Name: Name of the patient's primary doctor.
• 10. Dr. Phone Number: Contact number of the patient's primary doctor.
• 11. Medical Conditions: List any medical conditions that could impact vaccination.
• 12. Weight: Enter weight if the patient is less than 130 lbs.
• 13. Allergies: Indicate any allergies to medications, food, or latex.
• 14. Adverse Reactions: Indicate any past adverse reactions to vaccinations.
• 15. Seizures or Nervous System Problems: Indicate any history of seizures or neurological issues.
• 16. Signature/Legal Guardian: Patient's or legal guardian's signature to provide consent.
• 17. Date: Date when the consent form is signed.

Failing to submit the SHINGRIX Immunization Consent Form may result in the inability to receive the vaccine. This can lead to increased risk of shingles and its complications.

• Vaccination Delays: Without the consent form, the vaccination process may be delayed, postponing necessary protection against shingles.
• Ineligibility for Vaccination: Incomplete forms may lead to the patient being deemed ineligible for vaccination until all required information is provided.
• Legal and Medical Implications: Lack of a signed consent form poses legal and medical challenges for healthcare providers, preventing them from administering the vaccine.

• 1. Vaccination Appointments: Use this form when attending a scheduled SHINGRIX vaccination appointment.
• 2. Pre-Vaccination Screening: Complete the form during pre-vaccination screening to assess eligibility.
• 3. Legal Consent: Provide legal consent for receiving the SHINGRIX vaccine by signing this form.
• 4. Medical Documentation: Ensure accurate medical documentation by filling out this form with your personal and medical information.