Get Hy Vee Vaccine Consent Form

This guide provides clear and concise instructions on how to fill out the Hy Vee Vaccine Consent Form online. By following these steps, users can ensure that all necessary information is accurately captured, facilitating a smooth vaccination process.

Follow the steps to successfully complete the consent form.

1. Press the ‘Get Form’ button to access and open the Hy Vee Vaccine Consent Form in your preferred online editor.
2. Begin by entering your personal details in the designated fields. Fill in your first name, last name, gender, date of birth, contact number, and alternate number.
3. Indicate any known allergies by selecting 'Yes' or 'No'. If you choose 'Yes', please provide a list of your allergies.
4. Answer the question regarding immune deficiencies by selecting 'Yes' or 'No'.
5. If applicable, describe any known other conditions in the space provided.
6. Select the vaccines you consent to receive by ticking the appropriate boxes for each vaccine listed.
7. If you consent to a blood test, please indicate your agreement in the relevant section.
8. Provide your signature and the date to confirm your consent.
9. Fill in your general practitioner (GP) details including name, address, and contact number.
10. Include details of your next of kin by providing their name and contact number.
11. Optionally, check any health conditions that apply to your immediate biological family.
12. If financial consent is required, fill in your full name, address, telephone number, and sign the agreement.
13. Complete the payment information section if you wish to authorize Breakspear Medical Group for payment.
14. Once all fields are completed, save your changes and download the form for printing or sharing.

Complete your Hy Vee Vaccine Consent Form online today to ensure a seamless vaccination experience.