Vaccine Administration Record
1595 E Garrison Blvd Gastonia, NC 28054
Phone (704)865-3411 Fax (704)867-4262
Full Name
*
Sex
*
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Street
Street Address Line 2
City
State
Zip
Phone
*
Allergies
Race
Please Select
Not Specified
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Primary Care Physician
Doctor Phone Number
Screening Questions
Are you sick today?
*
Please Select
NO
YES
Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
*
Please Select
NO
YES
Have you ever had a serious reaction after receiving a vaccination?
*
Please Select
NO
YES
Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
*
Please Select
NO
YES
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?
*
Please Select
NO
YES
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, herpes, or cold sores?
*
Please Select
NO
YES
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?
*
Please Select
NO
YES
Have you had a seizure or a brain or other nervous system problem or Guillain Barre?
*
Please Select
NO
YES
During the past year, have you received a transfusion of blood or blood products or been given immune (gamma) globulin or antiviral drug (including acyclovir famciclovir, valacyclovir)?
*
Please Select
NO
YES
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
*
Please Select
NO
YES
Have you received any vaccinations or TB skin test in the past 4 weeks?
*
Please Select
NO
YES
Do you have a history of fainting, particularly with vaccines?
*
Please Select
NO
YES
For Tdap and adult Td: Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?
Please Select
Not Applicable
NO
YES
For Zoster: Have you had a past reaction to gelatin or triple antibiotic ointment?
Please Select
Not Applicable
NO
YES
Consent
I have read, or have had read to me, the written information regarding the vaccines being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccines 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 Akers Pharmacy Inc, 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 vaccines I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Akers Pharmacy Inc to administer the vaccines If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
*
Name (Please Print)
Signature
*
Date
*
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: