Patient Screening Form/ Vaccination Receipt
Date of Vaccination
*
/
Month
/
Day
Year
MM/DD/YYYY
Which vaccines would you like to receive during your appointment?
Flucelvax (seasonal flu vaccine for 4yrs and older)
Fluad (seasonal flu vaccine for 65yrs and older)
Pneumonia vaccine ( 65yrs and older or 18yrs and older with underlying conditions)
Shingrix ( shingles vaccines for 50yrs and older or 19yrs and older with underlying conditions)
Patient Name:
*
First and Last Name
DOB:
*
MM/DD/YYYY
Address
*
Street Address
APT #
City
State
Zip Code
Cell Phone #:
Email
example@example.com
Please answer the following questions
Are you sick today?
*
Yes
No
Do you have allergies to medications, food, a vaccine component or latex?
*
Yes
No
If, Yes Please Describe
Have you ever had a severe reaction after receiving a vaccination?
*
Yes
No
If, Yes Please Describe
Have you ever had seizure or brain or other nervous system problem?
*
Yes
No
If, Yes Please Describe
Have you ever had Guillain-Barre syndrome within the last 6 weeks?
*
Yes
No
Which arm would you like to get the injection on?
*
Right Deltoid
Left Deltoid
Immunizer Name
Signature Of Immunizer
Exp. Date
/
Month
/
Day
Year
Date
Lot #
Date:
/
Month
/
Day
Year
MM/DD/YYYY
Does the patient authorize this pharmacy to report the administration of this immunization(s) to the Citywide Immunization registry (CIR)?
Yes
No
Does the patient authorize this pharmacy to report the administration of this immunization(s) to their Primary Health Care Provider?
Yes
No
Patient Signature
*
Please Sign Above
Submit
Should be Empty: