GPS Flu Vaccine Registration - Adult
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  • Spanish (Latin America)

  • Seasonal Influenza Vaccine Consent Form

  • Today's Date
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  • PERSONAL INFORMATION

  • Date of Birth
     / /
  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

  • Do you have prescription insurance?

  • *Please bring your insurance card with you at the time of service, OR attach a copy of your prescription insurance card.

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  • PRIMARY

  • Do you have secondary prescription insurance?

  • SECONDARY

  • *Please bring your insurance card with you at the time of service, OR attach a copy of your prescription insurance card.

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  • Additional Vaccines you are interested in (can choose multiple):

  • This does not gaurantee we will have in stock, or be able to give additional vaccines. 

  • Screening Checklist for Contraindications to Vaccines for Adults

  • Date
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  • Date of Birth
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  • The following questions will help us determine which vaccines you may be given today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked.  If a question is not clear, please as your healthcare provider to explain it. 

  • 1. Are you sick today?*
  • 2. Do you have allergies to medications, food, a vaccine component, or latex?*
  • 3. Have you ever had a serious reaction after receiving a vaccination?*
  • 4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?*
  • 5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
  • 6. In the past 3 months, have you taken medications that affect your immune system, such as predinose, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments?*
  • 7. Have you had a seizure or a brain or other nervous system problem?*
  • 8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*
  • 9. For women: are you pregnant or is there a chance you could become pregnant during the next month?*
  • 10. Have you received any vaccinations in the past 4 weeks?*
  • Date
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  • Should be Empty: