Pre-Vaccination Checklist for Multiple Vaccines (Longmont)

Vaccination Consent for Vaccines

For vaccine recipients: The following questions will help us determine if there is any reason you should not get a vaccine. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked.
NOTE: WHEN ALL APPOINTMENT TIMES ARE GREY, WE HAVE RUN OUT OF SLOTS. WE ONLY LIST VACCINES WE HAVE AVAILABLE, IF YOU DON'T SEE WHAT YOU ARE LOOKING FOR THEN PLEASE CHECK BACK, AS WE WILL UPDATE AS MORE BECOME AVAILABLE.
Which Vaccine(s) do you need? (Select multiple if needed)*

PneumoniaShinglesTetanus/Diphtheria/PertussisRSVFlu (9+)High Dose Flu (65+)COVID 25-26 (Moderna)
When was your last dose of COVID vaccine?*
If you are signing up for a COVID vaccine and you are between 18-64 do you attest that you have an underlying medical condition that increases your risk of severe COVID-19
_____________________ (initials)
Have you had a Shingles shot before?*

YesNoDon't know
What date(s) were your previous dose(s) of Shingles vaccine?*
Have you had a pneumonia shot before?*

YesNoUnknown
What date(s) were your previous dose(s) of pneumonia vaccine?*
PLEASE ARRIVE ON TIME TO YOUR APPOINTMENT*
If you wish to schedule an appointment beyond the currently available dates, kindly utilize the following link to access our newly established vaccine processing site.

https://protect-us.mimecast.com/s/A1FHCBBG3qSl3v9fjBy_t?domain=pharmacy.imagemovermd.com
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's license number *
Sex*

MaleFemale
Race*

WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
What type of health insurance do you have?*
What is your Medicare part B number? (Red white and blue Card)*
N/A if not Medicare insured
What is your Medicaid ID #?*
N/A if not Medicaid insured
PRIVATE INSURANCE -what is the BIN #, Group # PCN#, and ID# on your prescription insurance card?*
N/A if not privately insured
Are you or your child sick today or have a fever?*

YesNoDon't know
Have you or your child had an allergic reaction to polysorbate, polyethylene glycol, or a previous dose of COVID-19 vaccine?*

YesNoDon't know
Have you or your child ever had a serious allergic reaction (anaphylaxis) to another vaccine or any injectable medication?*

YesNoDon't know
Have you or your child had severe allergic reaction (anaphylaxis) to foods, pets, venom, environmental or oral medications?*

YesNoDon't know
Do you or your child have a bleeding disorder, are on long-term aspirin therapy, or take other blood thinners?*

YesNoDon't know
Have you or your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) after receiving a vaccine?*

YesNoDon't know
Have you or your child had convalescent plasma or monoclonal antibodies as part of COVID-19 treatment in the past 3 months?*

YesNoDon't know
Have you received any dermal fillers (Juvaderm®, Restylane®, etc.)? (only applies to mRNA vaccines)*

YesNoDon't know
Do you or your child have a history of myocarditis or pericarditis? (Especially males ages 12-29 years after receiving a dose of mRNA vaccine)*

YesNoDon't know
Do you or your child have a weakened immune system or have had a solid-organ transplant? (HIV infection, cancer, kidneytransplant, etc.)**

YesNoDon't know
Do you or your child take immunosuppressive drugs or therapies? **

YesNoDon't know
Have you ever received a vaccine with Good Day Pharmacy?*

YesNo
By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions. I have read or had explained to me, and I understand the risks and benefits of receiving the vaccine. I have had a chance to ask questions, which were answered to my satisfaction. I hereby release this provider, its employees and its volunteers from any liability for any results which may occur from the administration of this vaccine.
Signature (click and hold mouse to sign)*

Clear
Date*

Name of EUA fact sheet or VIS provided:

Moderna

J&J

Pfizer

Pneumonia

Shingles

Influenza

Date Provided:

Dose given:

0.5 ml

0.3 ml

Route: IM

Site:

Left Deltoid

Right Deltoid

Pharmacist:

Date vaccine given:

Should be Empty:

Vaccination Consent for Vaccines

NOTE: WHEN ALL APPOINTMENT TIMES ARE GREY, WE HAVE RUN OUT OF SLOTS. WE ONLY LIST VACCINES WE HAVE AVAILABLE, IF YOU DON'T SEE WHAT YOU ARE LOOKING FOR THEN PLEASE CHECK BACK, AS WE WILL UPDATE AS MORE BECOME AVAILABLE.