PUBLIX Pharmacy Immunization Consent Form 2018 free printable template
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IMMUNIZATION CONSENT FORM Name: Birth date: / / Age: Sex: (M/F) Address: City: State: Zip: Phone: () Medicare ID# (Including Alpha): Publix Associates only Personnel Number: For Live Vaccines only
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How to fill out PUBLIX Pharmacy Immunization Consent Form
How to fill out PUBLIX Pharmacy Immunization Consent Form
01
Obtain the PUBLIX Pharmacy Immunization Consent Form from your nearest PUBLIX Pharmacy or their website.
02
Read the instructions provided on the form carefully.
03
Fill in your personal information including your name, date of birth, and contact information.
04
Indicate the specific immunization(s) you wish to receive.
05
Provide a brief medical history as requested on the form, including any current medications or allergies.
06
Sign and date the form to give consent for the immunization.
07
Review the completed form to ensure all information is accurate and legible.
08
Submit the form at the pharmacy during your appointment for vaccination.
Who needs PUBLIX Pharmacy Immunization Consent Form?
01
Individuals who want to receive vaccinations at PUBLIX Pharmacy.
02
Parents or guardians filling out the form for their minor children.
03
Anyone required to show proof of consent for immunizations due to work or school requirements.
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What is PUBLIX Pharmacy Immunization Consent Form?
The PUBLIX Pharmacy Immunization Consent Form is a document that allows patients to provide consent for receiving vaccinations at PUBLIX Pharmacy. It outlines the specific vaccines administered and ensures that patients understand the procedures and potential side effects.
Who is required to file PUBLIX Pharmacy Immunization Consent Form?
Individuals who wish to receive vaccinations at PUBLIX Pharmacy are required to fill out the Immunization Consent Form. This includes both adults getting vaccinated for themselves and parents or guardians filling out the form for minors.
How to fill out PUBLIX Pharmacy Immunization Consent Form?
To fill out the PUBLIX Pharmacy Immunization Consent Form, you must provide personal information such as your name, date of birth, and contact details, as well as details about the vaccine(s) being administered. After reading the consent statements, you must sign and date the form.
What is the purpose of PUBLIX Pharmacy Immunization Consent Form?
The purpose of the PUBLIX Pharmacy Immunization Consent Form is to obtain informed consent from patients before administering vaccinations, ensuring that they are aware of the benefits, risks, and potential side effects of the vaccines.
What information must be reported on PUBLIX Pharmacy Immunization Consent Form?
The information that must be reported on the PUBLIX Pharmacy Immunization Consent Form includes the patient's name, date of birth, address, phone number, vaccine type, and any relevant medical history or allergies that may affect the vaccination process.
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