689 Southbridge St, Auburn, MA 01501Call us at (508) 832-6511Open Mon–Fri: 8:30 a.m. – 7:00 p.m. · Sat: 9:30 a.m. – 4:30 p.m. · Sun: Closed689 Southbridge St, Auburn, MA 01501Call us at (508) 832-6511Open Mon–Fri: 8:30 a.m. – 7:00 p.m. · Sat: 9:30 a.m. – 4:30 p.m. · Sun: Closed
All formsPatient Form

Vaccine Consent

Required before any immunization. Please complete this form before your appointment so we can pre-screen and have everything ready.

Or call (508) 832-6511
01

Patient Information

02

Insurance Information

Most vaccines are covered with no out-of-pocket cost.

How would you like the vaccine billed?*
03

Vaccine Requested

Is this a follow-up / booster / 2nd-series dose?
04

Pre-Vaccination Screening

These questions help us determine whether the vaccine is right for you today.

Are you feeling sick today (fever, chills, recent illness)?*
Have you ever had a serious or allergic reaction to a vaccine, medication, latex, eggs, or yeast?*
History of Guillain-Barré Syndrome?*
Do you have an immune-system disorder (cancer, leukemia, HIV/AIDS) or take medication that affects immunity (chemotherapy, steroids, biologics)?*
Do you have a bleeding disorder, or take blood thinners (warfarin, Eliquis, Xarelto, etc.)?*
Have you received any vaccinations in the past 4 weeks?*
Have you received any blood transfusions, blood products, or immune globulin (Ig) in the past 12 months?*
History of fainting or seizure with injections?*
Are you pregnant, planning to be, or breastfeeding?
05

Vaccine Information Statement (VIS) Acknowledgement

Federal law (NCVIA) requires that you receive and read the VIS for the vaccine you are getting. We will provide a copy at your appointment.

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Signature

If the patient is under 18, a parent or legal guardian must sign.

I am signing as:*

HIPAA & Privacy Notice

Auburn Pharmacy & Home Health Care complies with the Health Insurance Portability and Accountability Act (HIPAA). The information you submit through this form is Protected Health Information (PHI) and will be used solely to fulfill your request, coordinate with your prescriber, and process insurance — never sold or shared with marketers.

This online form is not a secure method of communication; please do not include credit card numbers, social security numbers, or other highly sensitive data. By submitting, you authorize Auburn Pharmacy to use your information consistent with our Notice of Privacy Practices, available on request.

For medical emergencies, call 911. For urgent prescription needs, call us at (508) 832-6511.

Need help filling this out? Call us at (508) 832-6511 and we'll walk through it together.