Vaccine
Which vaccine(s) are you receiving?
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COVID-19
Flu
Shingles (Shingrix)
Pneumonia
Tetanus (Tdap)
RSV (Respiratory Syncytial Virus)
Vaccine Recipient Age
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Vaccine Recipient Information
Vaccine Recipient Name
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First Name
Middle Name
Last Name
Date of Birth
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/
Month
/
Day
Year
Current Date
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Month
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Day
Year
Date
Age
Parent/Guardian Information (must accompany minor at vaccination)
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Full Name
Relationship
Vaccine Recipient Physical Address
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Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Gender at birth
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Please Select
Male
Female
Race
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Please Select
American Indian or Alaska Native
Asian
Black or African American
Multi-racial
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
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Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
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Format: (000) 000-0000.
Mother's Maiden Name
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Required for proper vaccine documentation
Emergency Contact Name
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Relationship to Emergency Contact
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Phone Number of Emergency Contact
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Format: (000) 000-0000.
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General Vaccine Screening Questions
Answering "Yes" to any of the following questions does not prevent you from receiving a Vaccine, but instead may prompt our pharmacist to ask additional questions during your vaccination.
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Rows
No
Yes
1. Are you feeling sick today?
2. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
5. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia or other blood disorder?
6. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease MIS-C or MIS-A, herpes, or cold sores?
7. In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
8. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?
9. During the past year, have you received a transfusion of blood products, or been given immune (gamma) globulin (such as monoclonal antibodies or convalescent serum) or antiviral drug (including acyclovir, famciclovir, valacyclovir)?
10. For women: Are you pregnant or is there a chance that you could become pregnant during the next month?
11. Have you received any vaccinations, TB skin tests, or dermal fillers in the past 4 weeks?
12. Do you take a blood thinner, have a bleeding disorder, or have history of any bleeding disorder (e.g. heparin-induced thrombocytopenia or HIT)?
13. Do you have a history of fainting, particularly with vaccines?
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Insurance
Select your insurance coverage.
*
Please Select
Medicare
Commercial/Medicaid
Uninsured/No Coverage
Social Security Number
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Medicare Beneficiary Identifier
Can be found on Medicare issued red, white, and blue card.
Prescription Billing Information
Using your prescription insurance card, complete the fields below or upload a photo of your card using the file upload.
BIN
PCN
Group
ID
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Consent
General Vaccine Consent (check each box below after reading and prior to signing the form)
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Rows
Check each box
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
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Date Signed
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Month
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Day
Year
Date
Submit Consent Form (required)
Should be Empty: