{"id":6374,"date":"2022-08-05T14:16:38","date_gmt":"2022-08-05T19:16:38","guid":{"rendered":"https:\/\/guardianpharmacy.com\/kansas-missouri\/?page_id=6374"},"modified":"2022-08-05T14:16:38","modified_gmt":"2022-08-05T19:16:38","slug":"vaccine-consent-form","status":"publish","type":"page","link":"https:\/\/guardianpharmacy.com\/kansas-missouri\/vaccine-consent-form\/","title":{"rendered":"Vaccine Consent Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row full_width=&#8221;stretch_row&#8221; gap=&#8221;35&#8243; enable_first_overlay=&#8221;true&#8221; first_overlay_opacity=&#8221;100&#8243; first_background_type=&#8221;image&#8221; first_background_image=&#8221;4356&#8243; first_background_position=&#8221;bottom-center&#8221; first_background_repeat=&#8221;repeat-x&#8221;][vc_column][vc_row_inner][vc_column_inner width=&#8221;1\/6&#8243;][\/vc_column_inner][vc_column_inner width=&#8221;2\/3&#8243;][vc_custom_heading text=&#8221;Vaccine Consent Form&#8221; font_container=&#8221;tag:h2|font_size:42|text_align:center|color:%23002d5d&#8221; use_theme_fonts=&#8221;yes&#8221; css=&#8221;.vc_custom_1657567854127{padding-top: 30px !important;}&#8221;][\/vc_column_inner][vc_column_inner width=&#8221;1\/6&#8243;][\/vc_column_inner][\/vc_row_inner][vc_row_inner css=&#8221;.vc_custom_1657567375153{margin-top: 3em !important;margin-bottom: 70px !important;padding-top: 30px !important;padding-right: 50px !important;padding-bottom: 50px !important;padding-left: 50px !important;background-color: #eef2f6 !important;border-radius: 20px !important;}&#8221; el_id=&#8221;contact&#8221;][vc_column_inner]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_12' style='display:none'>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/kansas-missouri\/wp-json\/wp\/v2\/pages\/6374' data-formid='12' > \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_12_18\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_18\"><h3 class=\"gsection_title\">Section 1: Information for Individual Receiving Vaccine<\/h3><\/div><fieldset id=\"field_12_13\"  class=\"gfield gfield--type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_13\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_13'>\n                            \n                            <span id='input_12_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_12_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_13_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_12_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_13_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_5\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_5\"><label class='gfield_label gform-field-label' for='input_12_5' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_12_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_12_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_5' class='gform_hidden' value='https:\/\/guardianpharmacy.com\/kansas-missouri\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_12_41\"  class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_41\"><label class='gfield_label gform-field-label' for='input_12_41' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_41' id='input_12_41' type='text' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_12_8\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_8\"><label class='gfield_label gform-field-label' for='input_12_8' >Facility Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_12_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_12_9\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_9\"><label class='gfield_label gform-field-label' for='input_12_9' >Primary Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_12_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_12_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_21\"><legend class='gfield_label gform-field-label'  >Individual is:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_21'>\n\t\t\t<div class='gchoice gchoice_12_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Resident'  id='choice_12_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_21_0' id='label_12_21_0' class='gform-field-label gform-field-label--type-inline'>Resident<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Staff'  id='choice_12_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_21_1' id='label_12_21_1' class='gform-field-label gform-field-label--type-inline'>Staff<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_44\"><legend class='gfield_label gform-field-label'  >Insurance type:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_44'>\n\t\t\t<div class='gchoice gchoice_12_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Medicare'  id='choice_12_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_44_0' id='label_12_44_0' class='gform-field-label gform-field-label--type-inline'>Medicare<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Medical Insurance'  id='choice_12_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_44_1' id='label_12_44_1' class='gform-field-label gform-field-label--type-inline'>Medical Insurance<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_10\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_10\"><label class='gfield_label gform-field-label' for='input_12_10' >Medicare Part A\/B Number<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_12_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_12_12\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_12\"><label class='gfield_label gform-field-label' for='input_12_12' >Effective Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_12_12' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_12_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_12_12_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_12' class='gform_hidden' value='https:\/\/guardianpharmacy.com\/kansas-missouri\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_12_14\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_14\"><label class='gfield_label gform-field-label' for='input_12_14' >Medical Insurance Plan Name<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_12_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_12_15\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_15\"><label class='gfield_label gform-field-label' for='input_12_15' >Cardholder ID#<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_12_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_12_43\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_43\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Individual requests the following vaccination(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_12_43'><div class='gchoice gchoice_12_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Flu'  id='choice_12_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_43_1' id='label_12_43_1' class='gform-field-label gform-field-label--type-inline'>Flu<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Covid-19 (Booster)'  id='choice_12_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_43_2' id='label_12_43_2' class='gform-field-label gform-field-label--type-inline'>Covid-19 (Booster)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Covid-19 (Primary Series)'  id='choice_12_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_43_3' id='label_12_43_3' class='gform-field-label gform-field-label--type-inline'>Covid-19 (Primary Series)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_34\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_34\"><span style=\"font-size:15px;\"><a href=\"https:\/\/www.cdc.gov\/vaccines\/hcp\/vis\/vis-statements\/flu.pdf\" target=\"_blank\">Flu Vaccine Information Statement (PDF)<\/a><\/span><\/div><div id=\"field_12_46\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_46\"><span style=\"font-size:15px;\"><a href=\"https:\/\/www.fda.gov\/media\/144638\/download\" target=\"_blank\">COVID-19 Moderna fact sheet (PDF)<\/a><br><a href=\"https:\/\/www.fda.gov\/media\/153716\/download\" target=\"_blank\">COVID-19 Pfizer fact sheet (PDF)<\/a><\/span><\/div><div id=\"field_12_38\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_38\"><p> <\/p><\/div><div id=\"field_12_19\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_19\"><h3 class=\"gsection_title\">Section 2: Pre-Screening for Vaccine Eligibility<\/h3><\/div><div id=\"field_12_24\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_24\"><span style=\"font-size:16px;\">The following questions will help us determine which vaccines you may be given. Answering \u201cyes\u201d to any of these questions does not necessarily mean you should not be vaccinated.<\/span><\/div><fieldset id=\"field_12_23\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_23\"><legend class='gfield_label gform-field-label'  >Have you ever had a serious reaction after receiving a vaccination? For example: anaphylaxis (severe allergic reaction), Guillain-Barr\u00e9 Syndrome (a type of temporary severe muscle weakness)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_23'>\n\t\t\t<div class='gchoice gchoice_12_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_12_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_23_0' id='label_12_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_12_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_23_1' id='label_12_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_25\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_25\"><legend class='gfield_label gform-field-label'  >Do you have any allergies to medications, foods, or vaccines? For example: eggs, gelatin, thimerosal, neomycin, gentamicin, yeast, or latex?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_25'>\n\t\t\t<div class='gchoice gchoice_12_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_12_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_25_0' id='label_12_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_12_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_25_1' id='label_12_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_26\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_26\"><legend class='gfield_label gform-field-label'  >Do you have a history of seizure, brain problems, or nerve problems related to vaccination?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_26'>\n\t\t\t<div class='gchoice gchoice_12_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_12_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_26_0' id='label_12_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_12_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_26_1' id='label_12_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_27\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_27\"><legend class='gfield_label gform-field-label'  >Do you have chronic health conditions? (Heart, lung, kidney, or metabolic disease)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_27'>\n\t\t\t<div class='gchoice gchoice_12_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_12_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_27_0' id='label_12_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_12_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_27_1' id='label_12_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_28\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_28\"><legend class='gfield_label gform-field-label'  >Do you have an autoimmune condition or have taken immune suppressing medications? (Prednisone or other steroids, anticancer drugs, drugs for rheumatoid arthritis, Crohn&#039;s disease, or psoriasis)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_28'>\n\t\t\t<div class='gchoice gchoice_12_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_12_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_28_0' id='label_12_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_12_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_28_1' id='label_12_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_30\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_30\"><legend class='gfield_label gform-field-label'  >For women: Are you breastfeeding, pregnant or planning pregnancy in the next month?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_30'>\n\t\t\t<div class='gchoice gchoice_12_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_12_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_30_0' id='label_12_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_12_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_30_1' id='label_12_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_31\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_31\"><span style=\"font-size:15px;\"><em>* Please note those who have a moderate to severe illness with a fever should wait until they recover before getting vaccinated.<\/em><\/span><\/div><div id=\"field_12_39\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_39\"><p> <\/p><\/div><div id=\"field_12_32\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_32\"><h3 class=\"gsection_title\">Section 3: Consent for Vaccination<\/h3><\/div><div id=\"field_12_33\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_33\"><span style=\"font-size:15px;\">I give my consent to Guardian Pharmacy, LLC, its affiliates, subsidiaries, and the licensed healthcare professional administering the vaccine, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read, and\/or had explained to me the CDC\u2019s Vaccine Information Statement (VIS) or the FDA\u2019s Emergency Use Authorization (EUA) on the vaccine(s) I have elected to receive. I have had the opportunity to ask questions that were answered to my satisfaction. As with all medical treatments, I understand that there is no guarantee that I will not experience an adverse reaction from the vaccine. On behalf of the patient, the patient\u2019s heirs and personal representatives, I hereby release and hold harmless Guardian Pharmacy, LLC, and its affiliates, subsidiaries, staff, agents, successors, divisions, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the requested and vaccine(s). I understand and agree that the information contained on this form may be shared with my medical provider(s), the State Health Division (SHD), my state\u2019s health information exchange, state immunization registries, and\/or other state or federal government agencies as required by law, for the purpose of public health reporting, or for the purpose of care coordination. I further authorize Guardian Pharmacy to (a) release my medical or other information to Medicare, Medicaid, or other third-party payers as necessary to effectuate care or payment; (b) submit a claim to my insurer for the requested items and services; and (c) request payment of authorized benefits be made on my behalf to Guardian Pharmacy, LLC, its affiliates, or subsidiaries, with respect to the requested vaccine(s). I agree to be fully financially responsible for any cost-sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services, as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or immediately upon receipt of an invoice for the service. I agree to remain near the vaccination location for approximately 15-30 minutes after administration for observation. <\/span><\/div><div id=\"field_12_45\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_45\"><span style=\"font-size:15px;\"><p>DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.<\/p><\/span><\/div><div id=\"field_12_35\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_35\"><label class='gfield_label gform-field-label' for='input_12_35' >Signature of Patient or Authorized Representative<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_12_35' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_12_37\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_37\"><label class='gfield_label gform-field-label' for='input_12_37' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_37' id='input_12_37' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_37_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_12_37_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_37' class='gform_hidden' value='https:\/\/guardianpharmacy.com\/kansas-missouri\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_12_36\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_36\"><label class='gfield_label gform-field-label' for='input_12_36' >If Authorized Agent, Relation to Patient<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_12_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><div id=\"field_12_40\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_12_40\"><\/div><div id=\"field_12_47\"  class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_12_47\"><label class='gfield_label gform-field-label' for='input_12_47' >CAPTCHA<\/label><div id='input_12_47' class='ginput_container ginput_recaptcha' data-sitekey='6LdW4CMUAAAAANKBPmid6DUviZ-1_-ltT6RA0O2i'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_12' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_12\"]){return false;}  window[\"gf_submitting_12\"]=true; 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