VACCINATION CONSENT FORM - Pharmasave

VCE-01 / Aug 2020 VACCINATION CONSENT form Patient Name First _____ Last _____ Address _____ _____ Date of Birth (dd/mm/yyyy) _____ Phone Number _____ Emergency Contact Name _____ Phone Number _____ PHN _____ Gender M F X NOTE: Under provincial legislation pharmacists cannot give injections to children under 5 (under 7 in MB). Please answer the following questions: As of today: Yes No Are you experiencing any cold, flu or COVID-19-like symptoms, even mild ones? Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite.

VACCINATION CONSENT FORM . ... • Side effects from vaccination typically resolve within 2 to 3 days and, in most cases, an analgesic (pain killer) such as ... (as indicated on the back of this form) administered today. I have had the opportunity to have my questions answered.

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