Lange Nacht des Impfens am 12.11. · Wir impfen von 18–22 Uhr · Kommen Sie gerne einfach ohne Termin vorbei Lange Nacht des Impfens am 12.11. · Wir impfen von 18–22 Uhr · Kommen Sie gerne einfach ohne Termin vorbei

Über uns
Apotheken
Schwerpunkte
Kontakt
Karriere
Shop

Über uns
Apotheken
Schwerpunkte
Kontakt
Karriere
Shop

Impfkalender: aktuelle Impftage und Zeiten in der Leibniz Apotheke Berlin

MEDICAL HISTORY.

VACCINATION AGAINST COVID-19 & FLU

Please complete this medical history and consent form in full before your vaccination appointment. Your information will be transmitted securely after submission and will be available to the pharmacy before your appointment. Please bring your vaccination record with you to your appointment.

We only vaccinate people aged 18 and over. For persons who are unable to give consent themselves, the questions are answered by their legal representative.

Vaccines: COVID-19 – variant-adapted mRNA vaccine. Flu – influenza vaccine for the current season.

Bitte aktiviere JavaScript in deinem Browser, um dieses Formular fertigzustellen.

- Step 1 of 3

PERSONAL DETAILS

SURNAME, FIRST NAME: *

DATE OF BIRTH: *

ADDRESS: *

PHONE: *

MAIL: *

REQUESTED VACCINATION

GEWÜNSCHTE IMPFUNG *

COVID-19 · mRNA vaccine
Flu · influenza vaccine

QUESTIONS ABOUT YOUR HEALTH

1. Do you currently have an acute illness with fever? *

2. Have you received any vaccination in the last 14 days? *

to the Do

If yes, against what? *

3. Have you had a confirmed influenza or COVID-19 infection in the last 6 months?

If yes, when? *

4. Do you have surgery planned within the next 3 days? *

5. Have you ever had an allergic reaction, high fever, circulatory collapse or any other unusual reaction after a previous vaccination (e.g. against COVID-19 or flu)? *

If yes, which? *

6. Do you have a weakened immune system? *

For example due to an illness, chemotherapy or medication that suppresses the immune system.

If yes, due to what? *

7. Do you have a blood clotting disorder or do you take blood-thinning medication? *

8. Do you have any known allergies? *

For example to chicken egg protein or components of a vaccine.

If yes, which? *

9. Are you pregnant? *

CONSENT

YOUR DECLARATION

I have taken note of the information on vaccination against COVID-19 with an mRNA vaccine and/or vaccination
against flu (influenza):

Flu • German | Flu • Other languages | COVID-19 • German | COVID-19 • English

PLEASE SELECT ONE OF THE TWO OPTIONS: *

I consent to the proposed vaccination(s) as selected on page 1.
I decline the vaccination.

PLACE: *

DATE: *

Signature of the person to be vaccinated: *

Unterschrift löschen

Can the person to be vaccinated provide consent themselves? *

IF THE PERSON TO BE VACCINATED CANNOT GIVE CONSENT THEMSELVES

In this case, please sign as the person authorised to give consent (holder of a health care power of attorney or legal guardian) and provide your contact details.

SURNAME, FIRST NAME *

PHONE: *

MAIL: *

PLACE: *

DATE: *

SIGNATURE: *

Unterschrift löschen

Signature of the person authorised to give consent

DATA PROTECTION INFORMATION

Dear patient,

In connection with your vaccination, we – Leibniz Apotheke, Kantstraße 130B, 10625 Berlin, owner Dr. Stefan Rézépa – collect personal data from you as the controller. We process your name, address, date of birth, health insurance number and health insurer in order to carry out your vaccination, document it and later bill our services to your insurer. The legal basis for this processing is Art. 9(2)(h) GDPR in conjunction with the provisions of the German Social Code, Book V (SGB V), on vaccinations in pharmacies (performance of the treatment contract). This data is stored for 10 years and then deleted.

For the purpose of determining the uptake and effects of vaccinations (vaccination surveillance), the data specified there is transmitted to the Robert Koch Institute in accordance with Art. 9(2)(h) GDPR in conjunction with Section 13(5) of the German Infection Protection Act (IfSG).

Providing your data is generally voluntary. However, we cannot carry out the vaccination without your personal details. As a data subject, you have the right to access the personal data concerning you, to have incorrect data rectified and to have data erased if one of the grounds listed in Art. 17 GDPR applies, e.g. if the data is no longer needed for the purposes pursued. You also have the right to data portability and to restriction of processing. Furthermore, you have the right to lodge a complaint with a supervisory authority. If you have any questions about data protection, you can contact us at any time by email at leibniz@apotheke.berlin or by phone on 030 313 80 00.

DATA PROTECTION *