アメリカで予防接種！インフルエンザの予防接種の受け方と流れの体験談

• First Name
• Last Name
• Gender　Female/Male
• Date of Birth
• Home Adress/City/State/Zip
• Phone Number

Vaccine Requested:
Flu, Pneumococcal, Shingles, Tdap, Td, MMR, HepA, HepB, Meningococcal, Varicella, HPV, IPV

Is the person to be vaccinated sick or injured today?

If yes
Does the person have a new or moderate to high fever?
Does the person have a cough?
Does the person have diarrhea?
Has the person been vomiting?
Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?

Does the person to be vaccinated have allergies to medications, food components vaccine components, or latex? If yes, please list.

Examples:
eggs, bovine protein,gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, thimerosal

Does the person to be vaccinated have a chronic health condition or long-term health problem?

Examples:
heart, lung, kidney, neuromuscular, liver, metabolic, diseases, asthma, diabetes, anemia, other blood sidorders,neurologic or is the patient a smoker?

Has the person to be vaccinated ever had a reaction, fainted, or felt dizzy after receiving a vaccine or has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?

Has the person to be vaccinated ever had a seizure disorder for which they are on seizure medications, a brain disorder, Guillain-Barre Syndrome, or other nervous system problems?

Is the person to be vaccinated currently pregnant, considering becoming pregnant in the next month, or breast-feeding?

Does the person to be vaccinated have a weakened immune system, is in contact with anyone with a severely weakened immune system or in long-term treatment with drugs such as high-dose steroids?

Examples:
cancer, leukemia, lymphoma, HIV/AIDS, transplant, rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease or any other immune system disorder?

Please read the section below carefully and sign and date acknowledging that you understand and agree.

I hereby give my consent to Walmart, as applicable, to administer the medications(s)
I have requested above.
I understand the benefits and risks of receiving this medication and have received, read and/or had explained to me the Vaccine Information Statement on the vaccines(s)
I have elected to receive.
I acknowledge that I have had a chance to ask questions and that such questions were answerd to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 20 minites after administration for observation by the administering healthcare provider.
On behalf of myself, my heirs, and personal representatives I fully release and discharge Walmart, its staff, agents, successor, division, affiliates, officers, directors, and employees from any all liabillities or claims whether known or unknown arising in any way related to the administration of the vaccine(s) listed above.

I understand and acknowledge that the administration of this vaccine will be entered into my state’s immunization registry. I understand the purposes/benefits of my state’s immunization registry and acknowledge that, depending upon my state law, I may prevent disclosure of my immunization to the state registry with a signed Opt-Out.

The Pharmacist has informed me that I may have the right to refuse.

Initials:__________

I assign payment of authorized insurance benefits due to me to be said to the pharmacy. I consent to the release of medical information when necessary for billing reimbursement, and medical protocol.

Initials:__________

I am aware an immunization certified student pharmacist might be administering this medication.

Initials:__________

By initialing here, I acknowledge receipt of Walmart/Sam’s Club Health & Wellness Notices.I understand that the Notice is subject to change, and I can obtain a current Notice online at www.walmart.com, www.samsclub.com, or at any local store or club location.
Refusing to initial and acknowledge receipt will have no impact on my treatment.

Initials:__________

Patient/Legal Guardian Name:__________

Signature:__________

Date:__________