Pharmacy Agreement. Haven Bay Care Centre has a service agreement with College Road Pharmacy. As part of this agreement, the Pharmacist is required to safely supply, deliver and review your medication. There is no fee for this service. If you are happy for this pharmacy to serve you, please sign below: Resident (print) Resident signature: Or agreed in consultation with Resident’s Representative: Representative signature Date *Please note, this does not refer to the government levy whereby there is a fee for each item dispensed on a medical card. This is charged as a prescription levy Name: Date of Birth: Flu Vaccine Consent 2016 Name Of Resident : If you would like to receive the FluVaccine: I would like to receive the flu vaccine annually. Signed Date Date last known flu vaccination: Or agreed in consultation with Resident’s Representative: Representative signature Date If you would not like to receive the FluVaccine: No thanks, I would NOT like to receive the flu vaccine annually. Signed Date Or agreed in consultation with Resident’s Representative: Representative signature Date Date last known flu vaccination: Name: Date of Birth: Pneumonia Vaccine Consent 2016 Name Of Resident : Date of last pneumonia vaccination: If you would like to receive the pneumonia vaccine: I would like to receive the pneumonia vaccine. Signed Signed Representative Date If you would not like to receive the pneumonia vaccine: No thanks, I would NOT like to receive the pneumonia vaccine. Signed Date It is recommended that the pneumonia vaccine be given every 5 years. Please indicate the year you last received the pneumonia vaccine (if ever): Name: Date of Birth: Relative’s Contact Details & Post Resident’s Name: …………………………………………………………………… Relative’s Name: ……………………………………………………………………… Land Line No: ……………………………….. Mobile: ……………………………. Email: ……………………………………………………………………………….. Can we email you with updates such as our Newsletter instead of post? Yes No Can we contact you by text: Email Yes No Text Yes No Would you like to offer some of your time as a volunteer in the Home? Yes No Post: Post is be given directly to Resident or Alternatively
Pharmacy Agreement. To the extent legally permitted, Seller shall permit PLAN to have the benefit of the Pharmacy Agreement with PCS or any successor provider.
