Madison Pharmacy Shingrix (Shingles) Immunization Consent Form 2020-2025 free printable template
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HENDRIX (SHINGLES) IMMUNIZATION CONSENT FORM Patient Name Date of Birth Age Gender Male Female Address City State Zip Code Phone Number Primary Dr. Name Dr. Phone Number Which vaccine(s) would you
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How to fill out shingles consent form
How to fill out Madison Pharmacy Shingrix (Shingles) Immunization Consent Form
01
Obtain the Madison Pharmacy Shingrix Immunization Consent Form from the pharmacy or their website.
02
Fill in your personal information including your name, date of birth, and contact information at the top of the form.
03
Indicate whether you have a history of allergies, particularly to vaccines, by checking the appropriate boxes.
04
Review the information regarding Shingrix and its benefits and risks provided on the form.
05
Provide information about your medical history, including any current medications or medical conditions.
06
Sign and date the consent section to authorize the immunization.
07
Submit the completed form to the pharmacy staff at the time of your appointment.
Who needs Madison Pharmacy Shingrix (Shingles) Immunization Consent Form?
01
Individuals aged 50 years and older who wish to receive the Shingrix vaccine to protect against shingles.
02
Patients with a history of shingles or those at increased risk due to underlying health conditions.
03
Anyone who has not previously received the Shingrix vaccine or who needs a booster.
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What is Madison Pharmacy Shingrix (Shingles) Immunization Consent Form?
The Madison Pharmacy Shingrix (Shingles) Immunization Consent Form is a document that an individual must fill out to provide informed consent for receiving the Shingrix vaccine, which is designed to protect against shingles.
Who is required to file Madison Pharmacy Shingrix (Shingles) Immunization Consent Form?
Individuals who wish to receive the Shingrix vaccine at Madison Pharmacy are required to fill out and file the consent form.
How to fill out Madison Pharmacy Shingrix (Shingles) Immunization Consent Form?
To fill out the Madison Pharmacy Shingrix Immunization Consent Form, individuals should provide their personal information, answer medical history questions, and sign the document to indicate their consent to receive the vaccine.
What is the purpose of Madison Pharmacy Shingrix (Shingles) Immunization Consent Form?
The purpose of the Madison Pharmacy Shingrix Immunization Consent Form is to ensure that individuals understand the nature of the vaccine, its benefits, and possible side effects, thus allowing them to make an informed decision regarding their immunization.
What information must be reported on Madison Pharmacy Shingrix (Shingles) Immunization Consent Form?
The Madison Pharmacy Shingrix Immunization Consent Form must include personal identification information, medical history, allergies, prior vaccinations, and a signature for consent.
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