COVID 19 Vaccine Intake Fillable Consent Form

Flu (Influenza) - Seasonal

What You Need to Know

Flu (Influenza) is a respiratory disease that is caused by influenza viruses.
It is contagious and can cause mild to severe illness. If not properly addressed, it can sometimes lead to death.
Here are some of its symptoms:
- Chills
- Cough
- Sore throat
- Fever
- Runny or stuffy nose
- Headaches
- Tiredness
- Muscle or body aches
- Diarrhea (more common among older adults and children)
- Vomiting (more common among older adults and children)
Flu shots can help you be protected from flu virus.
The flu vaccine is effective approximately two weeks after administration as antibodies accumulate and provide protection against influenza virus. Thus, it is vital to have your flu shot before the flu begins to circulate around your area as you may be at risk to influenza during the two weeks after your flu shot.
The flu shot will not eliminate the risk of getting the flu 100%. However, research says that complications can be lessened and symptoms may be milder after a flu shot.
You Should Definitely Get a Flu Shot If:
- You are pregnant
- You are 65 years old or older
- You are at high risk of developing serious complications
- You are caring for other people who may be at high risk of developing serious complications
Common Side Effects of Flu Shots
- Soreness, redness, or swelling where the shot was given
- Mild Fever
- Aches

Get Vaccinated

Start Here

Shingles (Herpes Zoster)

What You Need to Know

Shingles (Herpes Zoster) is a result of the reactivation of the same virus that causes chickenpox, Varicella Zoster which remains in your body and goes to an inactive stage after treatment.
It manifests as a rash in the skin that looks like stripes of blisters that generally lasts 2-4 weeks.
Here are some of its most common symptoms:
- Chills
- Upset stomach
- Fever
- Headache
- Severe complications include:
- long-term nerve pain
- pneumonia
- blindness
- hearing problems
- brain inflammation
- and even death
A patient with shingles cannot infect another person
There are two vaccines available for shingles
- Shingrix®
- Zostavax®
Common Side Effects:
- For Shingrix®
  - Soreness, redness, or swelling where the shot was administered.
  - Headache, stomach discomfort, muscle pains, fatigue, fever, and shivering
- For Zostavax®
  - Pain, redness, or swelling where the shot was administered
  - Headache

Get Vaccinated

Start Here

Pneumonia (Pneumococcal)

What You Need to Know

Pneumococcal Pneumonia is a type of lung disease in the upper respiratory tract that can spread in the blood, lungs, middle ear or nervous system.
It is caused by streptococcus pneumoniae bacteria.
Pneumococcal Pneumonia is a contagious disease.
Children under 2 years old, seniors, and people with certain medical conditions may be more at risk of getting infected with Pneumococcal Pneumonia.
Two kinds of vaccines
- Pneumococcal Polysaccharide Vaccine
  
  -This is used to protect against the twenty-three most common types of streptococcus pneumoniae bacteria (PPSV23).
- Pneumococcal Conjugate Vaccine
  
  -This is administered to protect against the twenty-three most common types of streptococcus pneumoniae bacteria (PPSV23).
Who Should Get the Vaccine?
- For SV23
  
  -Individuals aged 2 to 64 years old who have chronic medical conditions (diabetes, lung disease, liver disease, chronic heart condition)
  
  -Individuals who smoke
  
  -Individuals who have alcoholism
Individuals aged 65 and older (even those who had the vaccine before they turned 65)
- For PCV13
  
  -Individuals aged 2 to 3 years old who have health conditions that lower their body's resistance to infection.
  
  -Individuals aged 65 and older who have no immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and have been recommended by their doctors to get PV13 immunization.
Possible Side Effects
- PPSV23
  - Redness or soreness where the shot was administered
  - Fever, muscle pains, and sleepiness
- PCV13
  - Redness, swelling, soreness, or tenderness where the shot was administered.
  - Sleepiness, headache, chills, fever, loss of appetite, and irritability.
In rare cases, individuals may have allergic reactions that can cause serious symptoms:
- Difficulty breathing
- Wheezing
- Hives
- Pale skin
- Fast heartbeat
- Dizziness

Get Vaccinated

Start Here

Tetanus, Diphtheria, Pertussis/Whooping Cough

What You Need to Know

Tetanus is a nerve issue that is caused by the toxin of common bacteria that can be found in soil, house dust, and others. It can enter the body through wounds, cuts, and scratches.
Diphtheria is a respiratory condition that may cause weakness, fever, sore throat, and swollen glands. More serious issues include heart failure, paralysis, and even death. It is highly contagious that can be spread by sneezing and coughing.
Pertussis is more commonly known as whooping cough. It is highly contagious and can be spread by coughing or by getting in contact with surfaces where droplets have landed. It can cause sneezing, nasal congestion, and runny nose that can lead to bouts of coughing.
Tdap and Td (Tetanus Booster) vaccines are used to help prevent these conditions.
Who Should Get the Vaccine?
- Pregnant Women
- Anyone with a severe burn or cut
- Adolescents aged 11-12 years old
Possible side effects
- Mild to moderate issues:
  
  -Pain, redness, or swelling where the shot was given
- Rare severe issues:
  
  -Deep, aching pain, and loss of muscle strength in the upper arm
- Serious allergic reactions, with symptoms including:
  - Swelling of the face and throat, difficulty breathing
  - Wheezing
  - Hives
  - Pale skin
  - Fast heartbeat
  - Dizziness

Get Vaccinated

Start Here

HPV (Human Papillomavirus)

What You Need to Know

Genital human papillomavirus (HPV) is a sexually transmitted virus. It is considered the most common sexually transmitted virus in the US. It generally does not cause symptoms and goes away on its own but it can cause cervical cancer among women. Apart from cervical cancer, HPV is also associated with vulvar cancers, vulvar cancers, and other types of cancer. It has also been found to cause warts in the throat and genitals.
There is no proven cure for Genital Human Papillomavirus. However, some issues associated with HPV have treatment.
The HPV vaccine has generally long-lasting effects and can cover against nine types of HPV.
Individuals aged 11 to 12 years old are recommended to get HPV Vaccine. For HPV vaccines to be effective, they should be given prior to exposure to HPV.
Possible side effects
- Mild to moderate issues:
  
  -Pain, redness, or swelling where the shot was given.
  
  -Fever and itchiness in the site of administration.
- Serious allergic reactions, with symptoms including:
  - Difficulty breathing
  - Wheezing
  - Hives
  - Pale skin
  - Rapid heartbeat
  - Dizziness

Get Vaccinated

Start Here

Meningitis (Meningococcal)

What You Need to Know

Meningitis is caused by an inflammation of the fluid and membranes surrounding a person's brain and spinal cord caused by meningococcal disease. Its common symptoms include headaches, fever, and stiffness in the neck, nausea, vomiting, eye light sensitivity, headaches, purple-spotted rash, and drop in blood pressure.
While this serious infection is rare and can affect anyone, it is most common among infants who are younger than 1 year old and those who have certain medical health issues.
Meningitis is potentially fatal. 10-15 percent of infected people can die even with antibiotic treatment.
The meningococcal conjugate vaccine (MCV4) helps individuals prevent meningococcal disease.
Who Should Get This Vaccine?
- Children aged 11 to 12 years old.
- Military recruits.
- College freshmen who live in dormitories.
- Individuals who live in an area with a meningitis outbreak.
- Individuals traveling to places where meningitis is common.
- Individuals who have removed or damaged spleen.
- Microbiologists who are exposed to the meningococcal bacteria.
Possible side effects
- -Pain, redness, or swelling where the shot was given.
- -Fever, sleepiness, and muscle pains
  - Rare severe issues:
  - Guillain-Barre syndrome
  - Serious allergic reactions, with symptoms including:
    - Difficulty breathing
    - Wheezing
    - Hives
    - Pale skin
    - Rapid heartbeat
    - Dizziness

Get Vaccinated

Start Here

MMR (Measles, Mumps and Rubella)

What You Need to Know

Measles, Mumps, and Rubella are highly contagious health conditions that can be spread through air.
Among the common symptoms of measles are cough, fever, runny nose, and pink eye and rash. If it affects the lungs, it can cause pneumonia. Among its serious effects is brain inflammation among older children.
Mumps is caused by the mumps virus. Its symptoms include swollen glands, headache, and fever. Serious health conditions caused by mumps include meningitis, deafness, swelling in the ovaries or testicles, and even death.
The rubella virus can cause low fever, rashes, and arthritis. Pregnant women who get infected by rubella can miscarry or may give birth to a baby with health defects.
The MMR vaccine is used to help protect individuals from measles, mumps, and rubella. It is often recommended among children.
Apart from children the following are recommended to get vaccinated with the MMR vaccine:
- Individuals who have not been vaccinated or are not aware if you have been vaccinated before.
- Individuals who were born after 1956.
- Individuals who work in medical facilities.
Possible side effects
- Mild-to-moderate problems:
  -Temporary pain and stiffness in the joints
  
  -Temporary low blood platelet count
  
  -Swollen glands in the cheeks or neck
  
  -Fever, rash, and seizures
- Rare severe problems:
  -Deafness
  
  -Permanent brain damage
- Serious allergic reactions, with symptoms including:
  -Hives
  
  -Pale skin
  
  -Fast heartbeat
  
  -Dizziness
  
  -Difficulty breathing
  
  -Wheezing

Get Vaccinated

Start Here

Chickenpox (Varicella)

What You Need to Know

Chickenpox is a highly contagious disease that is caused by infection with the varicella zoster virus. It can be spread through coughing, sneezing, and sharing of food. Its common symptoms include fever and itchy rashes that can often be located in individuals' trunks, scalp, and face. Unless they have been vaccinated with the varicella vaccine, most people can be infected with chickenpox at some point in their lives.
The vaccine for chickenpox is administered in a series of two shots; the first is given around the age of 12 to 18 months and the second at 4 to 6 years old.
Who Should Get Vaccinated?

-The chickenpox vaccine is often recommended to children aged 13 years old and under. It can also be administered to adolescents and adults who have not had chickenpox.
Possible Side Effects
- Mild-to-moderate problems:
  
  -Soreness, redness, or swelling at the site of injection
  
  -Mild rash
  
  -Mild to moderate fever
- Rare severe problems:
  
  -Seizure caused by fever
  
  -Pneumonia
- Serious allergic reactions, with symptoms including:
  
  -Hives
  
  -Paleness
  
  -Fast heartbeat
  
  -Dizziness
  
  -Difficulty breathing
  
  -Wheezing

Get Vaccinated

Start Here

Japanese Encephalitis

What You Need to Know

Japanese Encephalitis is a disease that is spread through mosquito bites that can be spread from one infected person through another.
Individuals who are infected with Japanese Encephalitis may not have symptoms but may have headaches or fever. If not treated, Japanese Encephalitis can lead to the swelling of the brain and even death.
The vaccine for Japanese Encephalitis is a two-dose vaccine that is administered 4 weeks apart. It is found effective in helping individuals prevent infection.
Who Should Get Vaccinated?
- Individuals aged 17 years old and above who are planning to travel to areas in Asia where the virus is prevalent.
- Biologists and medical experts who are constantly exposed to the virus.
- People who are at risk of exposure to the virus.
Possible side effects
- Mild-to-moderate problems:
  
  -Soreness, redness or swelling where the shot was given
  
  -Headache and muscle aches
- Rare severe problems:
  
  -Hives
  
  -Paleness
  
  -Weakness
  
  -Fast heartbeat
  
  -Dizziness
  
  -High fever or behavior changes
  
  -Difficulty breathing,
  
  -hoarseness or wheezing

Get Vaccinated

Start Here

Typhoid

What You Need to Know

Typhoid is a bacterial infection caused by the Salmonella typhi bacteria that can be fatal. It is often passed through contaminated water or food. Among its common symptoms include weakness, stomachaches, headaches vomiting, diarrhea, and high fever. It can also be contracted by having close contact with an infected individual.
Typhoid vaccine is administered to help people from getting infected by typhoid. However, it is not 100% effective so individuals who are expecting to travel in areas where typhoid infection is rampant must observe proper precautions with their food and water.
Who Should Get Vaccinated?
- Travelers who are planning to visit or move to places where typhoid is rampant.
- Travelers who are 2 years old and older.
- Travelers who can get close contact with infected individuals.
Possible side effects
- Mild-to-moderate problems
  
  -Abdominal pain, nausea, vomiting, diarrhea, headache
- Injection
  
  -Soreness, redness, or swelling where the shot was given
  
  -Headache, flu-like symptoms
- Oral
  
  -Fever, skin rash
- Rare severe problems:
  
  -Difficulty breathing
  
  -Wheezing
  
  -Hives
  
  -Pale skin
  
  -Fast heartbeat
  
  -Dizziness

Get Vaccinated

Start Here

Rabies

What You Need to Know

Rabies is a deadly disease that can be spread from the saliva of infected domestic and wild mammals. People get infected through bites and the onset of its symptoms can span from weeks or even years. If not immediately addressed, among its common symptoms include
- Hallucinations
- Seizures
- Confusion
- Insomnia
- Paralysis
Rabies vaccination is provided to help individuals be protected from rabies infection.
Who Should Get the Vaccine?
- Travelers to places where rabies is common.
- Veterinarians and other animal control professionals.
- Individuals who may have contact with animals who may be exposed to the rabies virus.
Possible side effects
- Mild-to-moderate problems:
  
  -Soreness, redness or swelling where the shot was given
  
  -Headache, nausea, abdominal pain, muscle aches and dizziness
  
  -Hives, pain in the joints and fever
- Rare severe problems:
  
  -Deafness
  
  -Permanent brain damage
- Serious allergic reactions, with symptoms including:
  
  -Hives
  
  -Pale skin
  
  -Fast heartbeat
  
  -Dizziness
  
  -Difficulty breathing
  
  -Wheezing

Get Vaccinated

Start Here

Hepatitis A/Hepatitis B Combination

What You Should Know

Hepatitis A

-Hepatitis A infection may have symptoms of jaundice, stomach pains, diarrhea, fever, and flu-like symptoms. It affects liver function and can be spread by having close contact or sexual relations with an infected patient or ingestion of contaminated water and food.
Hepatitis B

-Hepatitis B can either be acute like flu-like illness, weakness, diarrhea, muscle and joint pain, among others; or chronic which can lead to liver cancer, liver damage, and even death.
The hepatitis vaccine is often recommended to individuals aged 18 years and older who may be at a higher risk of getting infected by hepatitis A and B.
Possible side effects
- Mild-to-moderate problems:
  
  -Soreness, redness, or swelling where the shot was given.
  
  -Headache, tiredness, and loss of appetite.
- Rare severe problems:
  
  -Hives
  
  -Pale skin
  
  -Fast heartbeat
  
  -Dizziness
  
  -Difficulty breathing
  
  -Wheezing

Get Vaccinated

Start Here

Hepatitis B

What You Need to Know

Hepatitis B is highly contagious and can have cause serious issues in on a person's liver. It can be spread to contact with body fluids and blood from an infected person to an uninfected person. It can even be spread by using razors, toothbrushes, and other items that can be in contact with body fluids.
It can cause acute or chronic illnesses.
- Acute - is short-term and have symptoms including jaundice, diarrhea, muscle pain, weakness, appetite loss, joint pain, and vomiting
- Chronic - is long term and has serious damage to the health of one's liver. If not properly addressed, this could lead to death.
The hepatitis B vaccine is proven to help individuals prevent infection and is administered on a series of 2, 3 or 4 shots that is administered in over a 6-to-12 month period.
Who Should Get Vaccinated?

Children: 1st dose (birth), 2nd dose (between 1-2 months old), and 3rd dose (must be completed by 6-18 months old)

Individuals who have not been vaccinated
Adults who have a higher risk of getting infected:
Individuals aged 60 years old and below who have been recommended to have hepatitis B vaccination.
Individuals who want to travel to places where hepatitis B is rampant.
Individuals who have been infected by hepatitis C.
Individuals who are going through kidney dialysis.
Care staff for facilities that offer services for individuals with developmental disability
Individuals who may have contact with a person infected with the virus.
Professionals who regularly handle or encounter human blood.
Individuals who have HIV infection, chronic kidney disease, or chronic liver disease.
Individuals who are having sexual relations with the same sex.
Individuals whose sexual partner is infected with the virus.
Individuals who inject street drugs.
Possible side effects
- Mild-to-moderate problems:
  
  -Soreness, redness, or swelling where the shot was given.
  
  -Headache, tiredness, and loss of appetite.
- Rare severe problems:
  
  -Hives
  
  -Pale skin
  
  -Fast heartbeat
  
  -Dizziness
  
  -Difficulty breathing
  
  -Wheezing

Get Vaccinated

Start Here

Polio

What You Need to Know

Polio, or poliomyelitis, is a life-threatening disease that is caused by the poliovirus. It can be spread from an infected person to another uninfected person through close contact or through contaminated water or food. If not treated as soon as possible, it can affect an individuals’ spinal cord and may affect the person's ability to move (paralysis), respiratory failure, and even death.
The polio vaccine is used to help people be protected against polio.
Who Should Get Vaccinated?
- Medical and laboratory professionals who handle polio specimens.
- Medical professionals who have not been vaccinated and are treating individuals with the disease.
- Infants aged 2 months, 4 months, 6-18 months, and a booster at 4-6 years.
- Adolescents and adults who have not been vaccinated with the polio vaccine.
Possible side effects
- Mild-to-moderate problems:
  
  -Soreness, redness, or swelling where the shot was given.
- Rare severe problems:
  
  -Hives
  
  -Pale skin
  
  -Fast heartbeat
  
  -Dizziness
  
  -Difficulty breathing
  
  -Wheezing

Get Vaccinated

Start Here

Hepatitis A (Hep A)

What You Need to Know

Hepatitis A is a hepatitis virus that can affect liver functions due to inflammation. It can be spread by having close contact with an infected person, or through contaminated food and water.
Among its common symptoms include:
- Fever
- Diarrhea
- Jaundice
- Abdominal discomfort
To prevent the spread of hepatitis A, individuals are encouraged to observe proper hygienic practices including handwashing after using the toilet and changing diapers, and before preparing meals.
The hepatitis A vaccine is proven to be effective in helping people prevent infection. It is administered twice and six months apart.
Who Should Get Vaccinated?
- Individuals who have been exposed to the hepatitis A virus.
- Individuals who have work with animals infected with hepatitis A.
- Medical researchers that are frequently exposed to the virus.
- Individuals who are treated with clotting-factor concentrates for hemophilia or another medical condition.
- Individuals who use illegal injection and non-injection drugs.
- Men who are having sexual relations with other men.
- Children at the age of 1 year old.
- Individuals who have not been vaccinated before.
- Individuals who plan to travel to places where hepatitis A is rampant.
- Families who are planning to adopt children from places where hepatitis A is rampant.
Possible side effects
- Mild-to-moderate problems:
  
  -Soreness, redness, or swelling where the shot was given.
  
  -Headache, tiredness, and loss of appetite.
- Rare severe problems:
  
  -Hives
  
  -Pale skin
  
  -Fast heartbeat
  
  -Dizziness
  
  -Difficulty breathing
  
  -Wheezing

Get Vaccinated

Start Here

Express Pharmacy on Brimhall is now Inovia Pharmacy.Same Location. New Name. More Services.

Home > COVID 19 Vaccine Intake Fillable Consent Form

PLEASE READ BEFORE MAKING AN APPOINTMENT

IF YOU ALREADY GOT YOUR FIRST COVID-19 VACCINE DOSE AT OUR LOCATION, PLEASE PROCEED TO STEP 2 AND SUBMIT YOUR CONSENT FORM. YOU DO NOT NEED TO MAKE AN APPOINTMENT FOR YOUR SECOND DOSE.
“YOUR SECOND DOSE WAS SCHEDULED ALREADY ON THE DATE STATED ON THE BACK OF THE WHITE CARD AND YOU CAN JUST COME IN ON THAT DAY ANYTIME BETWEEN 10 am to 4 pm”

IF YOU ARE TRYING TO RESERVE YOUR FIRST DOSE, PLEASE CHECK AVAILABILITY BELOW. LIMITED AVAILABILTY DUE TO LIMITED SUPPLY.
NOTE THAT MORE SPOTS MAY OPEN UP DAILY AS WE RECEIVE ADDITIONAL VACCINE SUPPLY.

Step 1

Please choose an available time for your COVID-19 VACCINE. Then proceed to step 2 to complete and submit consent form.

Step 2

Fillout Consent Form

Flu (Influenza) - Seasonal

What You Need to Know

Here are some of its symptoms:

You Should Definitely Get a Flu Shot If:

Common Side Effects of Flu Shots

Get Vaccinated

Shingles (Herpes Zoster)

What You Need to Know

Here are some of its most common symptoms:

There are two vaccines available for shingles

Common Side Effects:

For Shingrix®

For Zostavax®

Get Vaccinated

Pneumonia (Pneumococcal)

What You Need to Know

Two kinds of vaccines

Pneumococcal Polysaccharide Vaccine

Pneumococcal Conjugate Vaccine

Who Should Get the Vaccine?

For SV23

Individuals aged 65 and older (even those who had the vaccine before they turned 65)

For PCV13

Possible Side Effects

PPSV23

PCV13

In rare cases, individuals may have allergic reactions that can cause serious symptoms:

Get Vaccinated

Tetanus, Diphtheria, Pertussis/Whooping Cough

What You Need to Know

Who Should Get the Vaccine?

Possible side effects

Mild to moderate issues:

Rare severe issues:

Serious allergic reactions, with symptoms including:

Get Vaccinated

HPV (Human Papillomavirus)

What You Need to Know

Possible side effects

Mild to moderate issues:

Serious allergic reactions, with symptoms including:

Get Vaccinated

Meningitis (Meningococcal)

What You Need to Know

Who Should Get This Vaccine?

Possible side effects

Get Vaccinated

MMR (Measles, Mumps and Rubella)

What You Need to Know

Possible side effects

Get Vaccinated

Chickenpox (Varicella)

What You Need to Know

Who Should Get Vaccinated?

Possible Side Effects

Mild-to-moderate problems:

Rare severe problems:

Serious allergic reactions, with symptoms including:

Get Vaccinated

Japanese Encephalitis

What You Need to Know

Who Should Get Vaccinated?

Possible side effects

Mild-to-moderate problems:

Rare severe problems:

Get Vaccinated

Typhoid

What You Need to Know

Who Should Get Vaccinated?

Possible side effects

Mild-to-moderate problems

Injection

Oral

Rare severe problems:

Get Vaccinated

Rabies

What You Need to Know

Who Should Get the Vaccine?

Possible side effects

Mild-to-moderate problems: