VACCINE GIVEN: _______________________
Arexvy
CONSENT DATE: ________________________________
see below
FOR IMMUNIZATION (WRITTEN) DOSE __ of __ (write 1 of 1 if not part of a series)
❶ CLIENT INFORMATION Complete Sections 1, 2, and 3 (please print)
Last Name: First Name: Date of Birth (YYYY/MM/DD):
Address: Telephone Number:
Emergency Contact and Relation: Emergency Telephone Number:
Personal Health Number: Sex: Pregnancy Status:
Female Male Transgender No Yes N/A
❷ OTHER HEALTH INFORMATION
My immune system is affected by a severe disease or medication. If checked, please specify: _________________________________________
I have had a serious life-threatening allergic reaction. Please specify: ____________________________________________________________
I have received another vaccine in the last 4 weeks. Please specify: ______________________________________________________________
❸ CONSENT Client Parent Legal guardian Representative
I understand the information in the HealthLink BC File(s) for the vaccine listed below. I understand the benefits and possible reactions of the vaccine
and the risk of not getting immunized. I have been informed of any medical reason why the vaccine listed below should not be given to me/my child.
I have had the opportunity to ask questions that were answered to my satisfaction. I understand this consent is valid for the vaccine listed below
unless the consent is cancelled.
I consent to receiving/for my child to receive, the vaccine listed below.
I will stay in the pharmacy for at least 15 minutes after the injection and seek medical attention if needed.
I will report any adverse effects I experience to the immunizing pharmacist.
I consent for the information collected on this form to be provided to my Family Physician (or Physician of my choice) and to the Health Authority
for entry into my immunization record. I understand the information will be used and disclosed in accordance with the Freedom of Information
and Protection of Privacy Act and that summary statistical information may be reported to the Ministry of Health.
Name (PRINT) ________________________________________ Phone ________________________________________
Signature __________________________________________ Date signed (YYYY/MM/DD) __________________________
FOR PHARMACIST USE ONLY
❹ VACCINE INFORMATION
Name of vaccine: ____________________
Arexvy DIN: ______________
02540207
Dose: ________
1 mL Site: LA / RA Route: IM / SC / ID / IN
Pharmacy Label
Lot #: _______________________________________________
Expiry date (YYYY/MM/DD): ________________________________
LA left arm; RA right arm; IM intramuscular; SC subcutaneous; ID intradermal; IN intranasal.
❺ PHARMACY INFORMATION
Pharmacist signature: _______________________________ License number: ____________________________________
17429
Date of administration (YYYY/MM/DD): ________________________Time of administration: _____________________________
17429
❻ CLIENT RESPONSE
Before: Normal Yes No ________________ 15-30 mins post-administration: Normal Yes No ______________
During: Normal Yes No _______________ Other comments: _________________________________________
Faxed to Public Health Unit: Yes No Faxed to Physician: Yes No
Name of Public Health Unit & Fax #: _____________________ Name of Physician & Fax #: _______________________
Last Updated: Sep 28, 2018
