Language
English (US)
Family Pharmacy Vaccine(s) Signup Form
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Prefer not to answer
Other
Race
*
African American
Native American
Asian
White
Native Hawaiian/ Other Pacific Islander
Prefer not to answer
Other
Ethnicity:
*
Hispanic or Latino
Non-Hispanic/Latino
Unknown
Prefer not to answer
Other
Primary Doctor Name
First Name
Last Name
I would like to get the following vaccine(s)-check all that apply:
Influenza Vaccine
Prevnar 13
Pneumovax 23
Shingrix (shingles)
Tdap
Other
Insurance Information
*
Commercial
Medicare
Uninsured
Insurance Company Name
*
Commercial Insurance Info
Member ID Number
Group Number
RX Bin Number
PCN
Medicare Information
Medicare Number
Part A Date
Part B Date
Insured Patients
I authorize the pharmacy to bill my insurance on my behalf for the immunization.
Uninsured Patients
I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan. I understand I will pay for the selected vaccine prior to getting vaccinated in the pharmacy.
Screening for Immunization
Does the person to be vaccinated have a fever or illness today?
*
Yes
No
Does the person to be vaccinated have an allergy to eggs, latex, or to a component of the vaccine?
*
Yes
No
Has the person to be vaccinated ever had a serious reaction to this vaccine in the past?
*
Yes
No
Has the person to be vaccinated ever had Guillain-Barre syndrome less than 6 weeks after vaccination, uncontrolled seizures or any unstable neurological disorder?
*
Yes
No
Has the person to be vaccinated received any vaccines in the past 30 days?
*
Yes
No
Is the person to be vaccinated currently pregnant, breastfeeding, or planning to become pregnant in the next 30 days?
*
Yes
No
Consent for Immunization
I, undersigned, agree with the following:
*
I certify that the information above is correct and accurate to the best of my knowledge.
I have been given a copy via email and can have explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving.
All my questions concerning the vaccine have been answered to my satisfaction.
I understand the benefits and risks of receiving the vaccine and request that it be given to me.
I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.
Date
*
-
Month
-
Day
Year
Date
Signature
*
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