IMMUNIZATION SCREENING AND CONSENT FORM

PATIENT INFORMATION

First Name: *

Middle Initial:

Last Name: *

Date of Birth *

Date

Phone Number

Please enter a valid phone number.

Email

example@example.com

Age: *

Gender: *

Ethnicity *

American Indian/Alaska Native Asian Black/African American Hispanic/Latino Native Hawaiin/Other pacific Islander White Other

Home Address: *

City: *

State: *

Zip: *

Primary Care Provider: *

Provider Phone

Please enter a valid phone number.

Provider Address:

Provider City

Provider State:

Provider Fax#

Please enter a valid phone number.

Which vaccine(s) would the patient like to receive today? *

The following questions will help us determine your eligibility to be vaccinated today. Yes/No Know

Are you feeling sick or experiencing a moderate to high fever today? *

Yes No Unsure

Do you have any allergies to medications, food (i.e. eggs), latex, vaccine component (e.g. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker's yeast or yeast)? If yes, please list: *

Yes No Unsure Other

Have you ever had a serious reaction to any vaccinations, including fainting and feeling dizzy? *

Yes No Unsure

Have you ever had a health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, or a blood disorder? If yes, please list: *

Yes No Unsure Other

Have you ever had a seizure disorder for which the patient is on seizure medication(s), a brain disorder, Guillain- Barré Syndrome (a condition that causes paralysis) or other nervous system problem?

Yes No Unsure

For a Woman only. Are you pregnant or or considfering becoming pregnant in the next month?

Yes No Unsure

Pneumococcal Vaccine *

Yes No Unsure

Shingles Vaccine *

Yes No Unsure

Tdap (Whooping Cough) Vaccine *

Yes No Unsure

Do you have insurance for your vaccine? *

Type of Insurance for Vaccine

Employer Name

Upload insurance card from file (Optional)

Take a photo of your insurance cards (Optional)

Insurance Employer Name (if applicable)

Insurance Rx Bin (if applicable)

Insurance Rx PCN (if applicable)

Insurance Relationship Code

Insurance Card Member ID

Insurance Rx Group (if applicable)

I certify that I am: (a) the patient and at least 18 years of age or (b) the parent or legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Byrd-Watson Pharmacy, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, 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 vaccine(s) listed above. I acknowledge that I understand the purposes/benefits of my state's immunization registry ("State Registry") and the Provider may disclose my immunization information to the State Registry. I acknowledge that, depending upon my state's law, I may prevent the disclosure of my immunization information by the applicable Provider to the State Registry by using the opt-out form. The Provider will, if my state permits, provide me with an Opt-Out Form. I understand that depending on my state's law, I may need to specifically consent, and to the extent required by my state's law, by signing below, I hereby do consent to the Provider reporting my immunization information to the State Registry. I understand that even if I do not consent or if I withdraw my consent, my state's laws may permit certain disclosures of my immunization information as required or permitted by law. I voluntarily authorize and direct my healthcare provider at Byrd-Watson Pharmacy to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of Byrd-Watson Pharmacy, my Primary Care Physician, my insurance and/or state or federal registries, where required, for the purpose of treatment, payment or other healthcare operations. I further 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.

(Please print clearly) *

Signature *

Clear

Date *

IMMUNIZATION SCREENING AND CONSENT FORM

SCREENING QUESTIONNAIRE

ALL VACCINES

HAS THE PATIENT HAD THE FOLLOWING VACCINES:

PATIENT NAME:

PATIENT SIGNATURE: