WP Immunization Scheduling

Full Name*

Date of Birth*

Date

Street Address*

City*

State*

Zip Code*

Phone*

Email (for confirmation)

example@example.com

Age*

Gender*

Are you pregnant?

YesNo

Vaccines to be given:*

ShinglesPneumoniaTetanus/DiptheriaTetanus/Diptheria/Pertussis

Do you have any allergies? Please list them below:

Screening Questions:*

	Yes	No
Are you currently sick with a moderate to high fever?
Do you have a bleeding disorder that makes you prone to bleeding?
If you use blood thinners, has your dose changed in the last 2 weeks?
Have you had a seizure or brain/nerve disorder such as Guillain-Barre Syndrome?
Are you allergic to any vaccine components? (discuss with pharmacist)
Have you had a serious reaction after receiving a vaccination? (discuss with pharmacist)

Are you allergic to eggs or egg products?

YesNo

Appointment*

Privacy Policy: I acknowledge that I have received the Watertown Pharmacy notice of privacy policy.

Agreement to Pay: I request that my health plan, insurance company, Medicare or Medicaid, as applicable, make payment for the services I receive at Watertown Pharmacy directly to Watertown Pharmacy. I understand that I am responsible for payment for any services that are not covered by any health plan, insurance company, Medicare or Medicaid, including co-payments and deductibles. I will be billed for the services provided and I will be responsible for payment.

1. I have read (or have had explained to me) the Vaccine Information Statement for the vaccine(s) I will receive today. I have had a chance to ask questions. All of my questions have been answered to my satisfaction. I understand the benefits and risks of the vaccine(s) and request that the vaccine(s) be given to me or my dependent. 2. I hereby hold harmless Watertown Pharmacy, and any supervising physicians, employees, and affiliates of these organizations from all responsibility for action that may occur as a result of the vaccination. This release shall be binding upon my heirs, assigns, executors, administrators, and personal representatives. By signing below, I am confirming that I understand and consent to the assignment of benefits, payment responsibility, treatment(s), and disclosures

Signature*

Clear

Name of person signing form:*

Date*

Date

If signed by anyone OTHER than the patient, mark the box that describes relationship to patient

ParentGuardianHealth Care AgentOther

PHARMACY USE ONLY:

PHARMACY USE ONLY