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Injection Consent Form Template

This document is a consent form for the administration of an injection by a pharmacist, requiring the patient to answer health-related questions. It outlines the responsibilities of the pharmacist and the patient, including the need for the patient to remain on-site for 15-30 minutes post-injection. The form also includes an authorization for emergency procedures and requires a signature for consent.

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61 views2 pages

Injection Consent Form Template

This document is a consent form for the administration of an injection by a pharmacist, requiring the patient to answer health-related questions. It outlines the responsibilities of the pharmacist and the patient, including the need for the patient to remain on-site for 15-30 minutes post-injection. The form also includes an authorization for emergency procedures and requires a signature for consent.

Uploaded by

chaiyut
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

APPENDIX B Consent for Administration of Injection

NOTE: THIS IS AN EXAMPLE ONLY AND SHOULD BE CUSTOMIZED AND


REVIEWED BY LEGAL COUNSEL

Please answer the following questions:


1. Are you sick today?

2. Do you have any allergies?

3. Are you on any medications?

If you are receiving a vaccine or immunization please answer the following questions:
4. Have you received any vaccinations in the last 6 weeks?

5. Have you ever had a serious reaction to a vaccine?

6. Do you have any condition that affects your


immune system, such as cancer ?
7. Women only: Are you pregnant or planning on
getting pregnant within the next month?

I understand that on (date), (the pharmacist) will


be administering (drug & dose).

I understand the pharmacist has received appropriate training and is registered to


administer injections by the Alberta College of Pharmacists. I understand the pharmacist
is aware of and agrees to comply with all professional standards surrounding
administering of injections as well as general pharmacy practice. The pharmacist
maintains current certification in cardiopulmonary resuscitation (CPR) and Basic First
Aid.

I understand and agree to remain at the location for 15-30 minutes after the injection as
directed by the pharmacist.

The pharmacist has provided me information around both the drug being administered
and the injection procedure so that I understand the expected outcome/reaction as well as
possible side effects. I understand that I may, at any time before, during, or after the
injection, ask the pharmacist further questions.

In the event of an emergency, I authorize the pharmacist to administer epinephrine and/or


apply necessary life saving procedures as an interim measure until medical support
personnel arrive. In the case of an emergency please contact
at .
I have read and understand the above information (name).

Signature (parent of guardian if a minor)


-------------------------------------------- ----------------------------
© Alberta Pharmacists' Association 2013
_____ (name) had (drug & dose)
administered on (date).

Store information/stamp Pharmacist signature


(please retain for your records or for other health care providers)

© Alberta Pharmacists' Association 2013

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