Article Guide
The Costco Immunization form serves as a comprehensive document that streamlines the process of obtaining vaccinations. It collects essential patient information, including the individual's name, contact details, and Medicare ID number, ensuring accurate record-keeping. The form also addresses vital health considerations by asking a series of health-related questions. This section seeks to identify any allergies, past reactions, or current health issues that could affect vaccine administration. Additionally, it includes a consent section where individuals or legal guardians acknowledge understanding the potential risks associated with vaccinations while releasing liability from Costco and its affiliates. The document outlines adverse reactions, emphasizing the importance of monitoring after vaccination. Specific sections are designated for recording vaccine details, such as type, expiration date, and dosage, allowing for efficient tracking by healthcare providers. Finally, the form reinforces the importance of sharing a copy with one’s physician for inclusion in permanent medical records. Credentialed healthcare staff will utilize this form to enhance patient safety and ensure an effective immunization process.
Form Sample
IMMUNIZATION CONSENT FORM
PATIENT’S LAST NAME |
PATIENT’S FIRST NAME |
MI |
GENDER (M/F) |
|
|
|
|
|
|
ADDRESS |
CITY |
|
STATE |
ZIP |
|
|
|
|
|
MEDICARE ID NUMBER |
|
BIRTH DATE (MM/DD/YYYY) |
||
|
|
|
|
|
PRIMARY HEALTHCARE PRESCRIBER |
PRESCRIBER ADDRESS |
PRESCRIBER PHONE/FAX |
VACCINE REQUESTED |
|
PRECAUTIONS AND CONTRAINDICATIONS (Please check yes or no for each question.)
1. |
Are you sick today? |
r Yes r No |
2. |
Do you have allergies to medications, food or vaccines? |
r Yes r No |
|
Allergies ___________________________________________________________ |
|
3. |
Have you ever had a serious reaction after receiving a vaccination? |
r Yes r No |
4.Do you have a
or other blood disorder? |
r Yes r No |
5.Do you have cancer, leukemia, AIDS or any other immune system problem? r Yes r No
6.Do you take cortisone, prednisone, other steroids or
or have you had |
r Yes r No |
7. Have you had a seizure, brain or nerve problem? |
r Yes r No |
8.During the past year, have you received a transfusion of blood or blood products, or been given a medicine called
immune (gamma) globulin? |
r Yes r No |
9. For women: Are you pregnant or is there a chance you could |
|
become pregnant during the next month? |
r Yes r No |
10.Have you received any vaccinations in the past 4 weeks? |
r Yes r No |
If yes, what vaccines? _________________________________________________
11.Are you allergic to eggs? |
r Yes r No |
12.Are you allergic to latex? |
r Yes r No |
ADVERSE REACTIONS
A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of any vaccine causing serious harm, or death, is extremely small.
Local symptoms may include: slight tenderness, redness, itching or swelling at the site of injection.
Systemic symptoms may include: fever, malaise and muscle pain. Other systemic symptoms may occur infrequently. These reactions usually begin 6 to 12 hours after immunization and can persist for a few days. Immediate presumable allergic reactions such as hives, angioedema, allergic asthma or systemic anaphylaxis occur rarely after immunization. These reactions may result from hypersensitive reactions in people with severe egg allergy, and such people should not be given certain vaccines that contain eggs. People with documented immunoglobulin E (IgE)- mediated hypersensitivities to eggs or any other vaccine components, including thimerosal, may also be at increased risk of reactions from immunizations.
In the case of a severe reaction such as a high fever, behavior changes or
|
|
|
ADMINISTRATIVE RECORD |
FOR PHARMACY USE ONLY |
|
|||
VACCINE: __________________ |
EXPIRATION DATE: _________ |
|
VACCINE: __________________ |
EXPIRATION DATE: _________ |
|
VACCINE: __________________ |
EXPIRATION DATE: _________ |
|
|
|
|||||||
VIS VERSION:________________ |
SITE OF INJECTION: ________ |
|
VIS VERSION:________________ |
SITE OF INJECTION: ________ |
|
VIS VERSION:________________ |
SITE OF INJECTION: ________ |
|
MANUFACTURER: ____________ |
DOSAGE: ________________ |
|
MANUFACTURER: ____________ |
DOSAGE: ________________ |
|
MANUFACTURER: ____________ |
DOSAGE: ________________ |
|
LOT NUMBER: _______________ |
ROUTE OF ADMIN: _________ |
|
LOT NUMBER: _______________ |
ROUTE OF ADMIN: _________ |
|
LOT NUMBER: _______________ |
ROUTE OF ADMIN: _________ |
|
|
|
|
|
|
|
|
|
|
|
|
|
PAYMENT INFORMATION |
FOR PHARMACY USE ONLY |
|
|||
|
|
|
|
|
|
|
|
|
VACCINE FEES |
|
|
TOTAL CHARGE |
|
|
|
|
|
“I have read the adverse reactions associated with the administration of vaccines. A copy of the vaccine manufacturer’s drug information sheet is available on request. Furthermore, I have also had an opportunity to ask questions about these immunizations. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization(s) or the receipt of the immunization(s) by the person named below for whom I am the legal guardian (‘Ward’). My medical record may be shared with my physician or other healthcare provider and the medical record of my Ward may be shared with his/her physician or other healthcare provider. I am requesting that the immunization(s) be given to me or my Ward. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release Costco, and its affiliates, subsidiaries, divisions, directors, contractors, agents and employees (collectively “Released Parties”), from any and all claims arising out of, in connection with or in any way related to my receipt and the receipt by my Ward of this or these immunization(s). Neither Costco nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable, responsible or any way accountable for any loss, injury, death or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described above. Costco will use and disclose your personal and health information or the personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies in regard to you and your Ward’s personal health information. I acknowledge that I have received a copy of the Notice of Privacy Practices.”
|
|
|
|
|
|
SIGNATURE/LEGAL GUARDIAN |
|
DATE OF VACCINATION/DATE VIS GIVEN |
|
|
|
|
|
|
|
|
|
PRINT NAME |
|
PHARMACIST/PRESCRIBER SIGNATURE |
|
|
|
|
|
|
|
|
|
|
|
PHARMACY NAME/ADDRESS |
|
|
|
|
|
|
|
|
|
PLEASE PROVIDE A COPY OF THIS FORM TO YOUR PHYSICIAN AND/OR HEALTHCARE PROVIDER FOR YOUR PERMANENT MEDICAL RECORDS. |
|
|
|
||
WHITE – ADMINISTRATIVE COPY |
YELLOW – PATIENT COPY |
12AB1202 |
7/12 |
||
|
|
|
|||
Document Specifications
| Fact Name | Description |
|---|---|
| Basic Information | The Costco Immunization Form requires the patient's name, gender, address, and phone number. |
| Medicare ID | Patients must provide their Medicare ID number if applicable. |
| Health Questions | The form contains a series of health questions to determine the suitability of vaccination. |
| Allergy Disclosures | Patients must disclose any allergies to medications or vaccines. |
| Adverse Reactions | Information about possible reactions to vaccines is provided, emphasizing the rarity of serious issues. |
| Legal Guardian Consent | If the patient is a minor, a legal guardian must sign the form to consent to immunization. |
| Privacy Notice | The form includes a statement acknowledging the receipt of a Notice of Privacy Practices. |
| Record Keeping | A copy of the form is intended for both the patient and physician for medical record-keeping. |
| State Specifics | For certain states, additional regulations and laws governing immunization may apply. |
Steps to Filling Out Costco Immunization
After you obtain the Costco Immunization form, it’s essential to fill it out accurately to ensure a smooth vaccination process. This form requires personal details, healthcare information, and answers to health-related questions. Be prepared to provide information about allergies and any past reactions to vaccinations. Follow these steps to complete the form thoroughly.
- Write your last name in the designated space for PATIENT’S LAST NAME.
- Fill in your first name for PATIENT’S FIRST NAME.
- Add your middle initial (if you have one) in the MI field.
- Select your gender by marking gender (M/F).
- Enter your complete address, including street, city, state, and ZIP code.
- Provide a 10-digit phone number where you can be reached.
- Input your Medicare ID number if applicable.
- Enter your birth date in the format (MM/DD/YYYY).
- Write the name of your primary healthcare prescriber.
- Fill in your prescriber’s address.
- Provide the prescriber’s phone or fax number.
- Indicate the vaccine requested.
Next, address the safety questions. These help ensure that vaccination is appropriate for you or the person you are representing.
- Answer if you are sick today by checking Yes or No.
- Indicate if you have allergies to medications, food, or vaccines by checking the appropriate box and listing any specific allergies.
- Say if you’ve had a serious reaction to any vaccination before. Select Yes or No.
- Answer whether you have a long-term health problem listed on the form.
- Respond to whether you have cancer, leukemia, AIDS, or any immune system issues.
- Indicate if you take specific medications or have received certain treatments.
- Answer if you have had seizures or other brain/nerve issues.
- Indicate if you’ve received blood transfusions or immune globulin in the last year.
- For women, confirm if you are pregnant or might become pregnant soon.
- Answer if you’ve had any vaccinations in the past four weeks and list them if applicable.
- Indicate if you are allergic to eggs.
- Confirm if you are allergic to latex.
Finally, read and acknowledge the statement regarding adverse reactions to vaccines before signing the form. This ensures you understand the information and agree to the terms.
- Sign and date the SIGNATURE/LEGAL GUARDIAN section.
- Fill in the DATE OF VACCINATION/DATE VIS GIVEN field.
- Print your name in the PRINT NAME section.
- Have the pharmacist/prescriber sign the form.
- Write the pharmacy name and address.
- Ensure you keep a copy for your records and provide one to your healthcare provider.
With careful attention to each section, you’ll complete the Costco Immunization form correctly. This helps ensure the vaccination process goes smoothly for you or your dependent.
More About Costco Immunization
What is the Costco Immunization Form used for?
The Costco Immunization Form is designed to gather essential information about a patient receiving a vaccination. It captures personal details, vaccination history, and any health precautions necessary to ensure safety during the vaccination process.
Who needs to fill out this form?
Any individual receiving a vaccination at Costco must complete this form. Additionally, a legal guardian can fill it out for minors or individuals unable to provide their own consent.
What personal information is required on the form?
The form requires the patient's full name, gender, address, phone number, Medicare ID number, birth date, and details about the primary healthcare prescriber, including their contact information. This information helps ensure proper documentation and communication regarding the patient's health.
What are the precautions and contraindications?
Patients must answer questions regarding their current health status and any allergies or previous reactions to vaccines. These questions help identify individuals who may be at risk for adverse reactions, thereby ensuring their safety during the vaccination process.
What should I do if I have allergies or past reactions?
If you have allergies to medications, food, or previous vaccinations, or if you've experienced severe reactions in the past, it's vital to disclose this information on the form. Your healthcare provider will use this information to assess your eligibility for the vaccine and discuss potential alternatives if necessary.
What happens if I experience an adverse reaction after vaccination?
In the rare event that you experience an adverse reaction, such as a high fever or difficulty breathing after vaccination, seek medical attention immediately. It's essential to be aware of symptoms like hives, paleness, or dizziness, as these might indicate an allergic reaction.
Is my personal information safe with Costco?
Costco is committed to protecting your personal and health information. The form includes a section about the use and disclosure of your information, including sharing it with healthcare providers for treatment and quality improvement. A detailed Notice of Privacy Practices is also provided for your understanding.
Why do I need to sign the form?
Signing the form indicates that you understand the information provided, have had the opportunity to ask questions, and are consenting to receive the vaccination. This also acknowledges that you assume responsibility for any reactions that may occur.
What should I do with a copy of the completed form?
After completing the form, you should keep a copy for your records and provide a copy to your healthcare provider. This ensures that your vaccination history is documented and available in your medical records, which is helpful for future healthcare decisions.
Are there any fees associated with the vaccination?
Yes, there may be fees associated with receiving the vaccine. These fees will be specified by Costco and should be clearly stated on the form. Knowing the costs in advance will help you plan accordingly.
Common mistakes
-
Incomplete Personal Information: Individuals often forget to fill in all required fields such as last name, first name, address, or phone number. Double-check your entries to ensure all information is complete.
-
Not Answering All Yes/No Questions: Some people skip questions related to health conditions or current medications. Each question is crucial for assessing your vaccination safety. Take your time to answer all of them.
-
Missing Signatures: Failing to sign the consent section is a common mistake. Without a signature, the form is not valid. Ensure you or your legal guardian completes this step.
-
Neglecting to Review Adverse Reactions: Some individuals overlook the section about possible side effects of the vaccine. It’s essential to read and understand this information thoroughly. Knowing the risks can help you make informed decisions regarding your health.
Documents used along the form
The Costco Immunization form serves as a vital document for individuals seeking vaccinations, detailing personal information, medical history, and consent. Along with this form, various other documents and forms may typically be utilized to ensure a seamless immunization process. Below is a comprehensive list of these forms along with concise descriptions for each one.
- Patient Registration Form: This form collects essential information from the patient upon their initial visit. It includes personal details, emergency contacts, and insurance information, which help healthcare providers coordinate care effectively.
- Medical History Form: Prior to receiving a vaccine, patients often need to fill out a medical history form. This document gathers pertinent health background details, including previous illnesses, surgeries, and allergies, assisting healthcare providers in determining vaccine suitability.
- Vaccine Information Statement (VIS): This document provides crucial information about the vaccine being administered. It details potential side effects, benefits, and risks, ensuring that patients can make informed decisions regarding their immunizations.
- Immunization Record: This is an official record documenting all vaccinations a person has received. It is necessary for school entry and may be requested by other healthcare providers to verify vaccination status.
- Consent for Minors Form: For individuals under the age of 18, a parental or guardian consent form is often required. It authorizes the administration of vaccines to minors and signifies that a responsible adult is informed and has approved the immunization.
- Insurance Information Form: Patients may need to fill out this form to provide details about their health insurance coverage. It assists in billing and ensures that the costs associated with the vaccine can be processed appropriately.
- Emergency Contact Form: This form lists individuals who can be contacted in case of an emergency during the immunization visit. It is crucial for safeguarding patient health and ensuring swift communication.
- Adverse Event Reporting Form: After immunization, this document is used to report any unexpected side effects or reactions. The information collected is valuable for monitoring the safety of vaccines at a broader level.
- Privacy Notice Acknowledgment: Patients must acknowledge receipt of the provider's privacy notice. This document informs them about how their personal and health information will be used and protected.
- Follow-Up Appointment Notification: Some immunizations require a second dose. This form serves to remind patients of any necessary follow-up appointments, ensuring a complete vaccination process.
These accompanying documents are essential for ensuring that the immunization process is not only compliant with healthcare regulations but also safe and effective for all involved. By understanding and utilizing these forms, patients can navigate the vaccination process with confidence and clarity.
Similar forms
The Costco Immunization form shares similarities with the patient intake form often used in medical practices. Like the Costco form, the patient intake form collects vital personal details about the individual such as their name, address, and contact information. Additionally, it often includes questions about medical history, allergies, and current medications. This information helps healthcare providers make informed decisions about the patient's care. Both forms serve an administrative purpose, ensuring that the provider has comprehensive background knowledge to facilitate safe treatment.
Another document akin to the Costco Immunization form is the consent form for medical procedures, which also seeks consent from patients before administering a treatment. This type of form typically outlines the procedure, potential risks, and benefits, much like the vaccine risks detailed in the Costco form. Patients must acknowledge their understanding of what to expect and confirm their agreement to proceed. Each serves to protect both the patient and the provider by ensuring informed consent is obtained prior to any medical action.
The medical release form is another document that relates closely to the Costco Immunization form. This form is designed to share a patient’s medical records with other healthcare providers, similar to how the Costco form states that medical records may be shared with the patient’s physician. Both documents prioritize patient confidentiality and require the patient’s signature to authorize the exchange of sensitive health information. Ultimately, they help maintain a continuum of care in medical settings.
In addition, the medication administration record (MAR) bears resemblance to the Costco Immunization form. The MAR is a document used by healthcare providers to detail medications administered to a patient, including immunizations. Like the Costco form, which specifies what vaccine was given and its lot number, the MAR ensures that the right doses are recorded, helping to track the patient’s medication history. This helps prevent errors and provides a clear record of all treatments the patient has received.
Finally, the health history questionnaire is similar to the Costco Immunization form in the way it collects comprehensive data regarding the patient's past health issues and medications. This document often includes questions about previous vaccinations and adverse reactions, correlating with the precautionary questions on the Costco Immunization form. Both forms ensure that healthcare professionals can assess risks effectively and provide tailored care based on individual medical histories. These forms ultimately serve the same goal: to safeguard the patient and optimize health outcomes.
Dos and Don'ts
When filling out the Costco Immunization form, it is important to be thorough and accurate. Below are some key things to keep in mind.
- Do read the entire form carefully before starting to fill it out.
- Do provide accurate personal information, including your last name, first name, and contact details.
- Do check each precaution or contraindication question honestly.
- Do disclose any allergies, especially to medications or vaccines.
- Do inform the healthcare provider of any previous serious reactions to vaccinations.
- Do sign the consent section, confirming that you understand the risks and benefits.
- Don't leave any fields blank unless instructed to do so.
- Don't rush through the questions without thinking them through.
- Don't hesitate to ask questions if something is unclear or if you need assistance.
Misconceptions
Understanding the Costco Immunization form is essential for ensuring a smooth vaccination process. However, several misconceptions can lead to confusion. Here are five common misunderstandings:
- The form is only for adults. The Costco Immunization form can be used for minors as well, provided that a legal guardian signs it on their behalf.
- Providing medical history is optional. It is essential to answer all medical history questions accurately. This information is critical for the healthcare provider to assess any potential risks.
- The form guarantees no side effects. While vaccines are generally safe, the form explicitly states that adverse reactions can occur. Understanding the risks helps individuals make informed decisions.
- You can leave sections blank. Every section should be completed fully. Incomplete forms may cause delays in the vaccination process.
- Costco is not responsible for injuries from vaccinations. The form includes a waiver that indicates Costco and its associates are released from liability in case of any adverse reactions, which is standard practice for many immunization programs.
Key takeaways
When filling out and using the Costco Immunization form, consider the following key points:
- Correct Information: Ensure that all personal details, including your name, address, and phone number, are accurate to avoid any complications.
- Health History: Be thorough when answering medical history questions. This includes allergies, past reactions to vaccines, and any existing health conditions.
- Pregnancy Disclosure: If applicable, indicate whether you are pregnant or may become pregnant. This information is crucial for vaccine safety.
- Recent Vaccinations: Note any vaccines received in the past four weeks. This helps evaluate the appropriateness of the current vaccination.
- Understanding Risks: Familiarize yourself with potential adverse reactions. Knowing what to expect can help in assessing any changes post-vaccination.
- Privacy Acknowledgment: The form includes a section about the use of your personal health information. Make sure to understand how this information will be used.
- Keeping Copies: After completion, retain a copy of the form for your records. This is important for follow-up appointments and medical records.