Vaccine Screening Checklist

Vaccination Date*

Date

Patient Name*

Date of Birth*

Date

ParentGuardian Surrogate If Applicable Please Print

Address*

Address

Street Address Line 2

TownState

Zip

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell *

Please enter a valid phone number.Format: (000) 000-0000.

Gender*

Race*

Ethnicity*

SSN

Proof of ID*

Medical Insurance*

Medicare Part B*

Prescription Insurance*

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 unclear, please ask your healthcare provider to clarify it.

Have you had any allergic or adverse reaction to any vaccination?*

If yes please list

Are you currently taking any medications?*

If yes please list

Have you ever had an allergic reaction to any medication(s)?*

If yes please list

Have you ever had an allergic reaction to any food?*

If yes please list

Do you have an allergy to latex?*

Have you ever had any other allergies or allergic reactions, in addition to those described above?*

If yes please list

Have you been sick or had a fever of 101 degrees F or higher in the past 48 hours?*

Have you had a seizure or other neurological problems?*

Do you have (or at risk that you have) cancer, leukemia, HIV, AIDS or any other immune system problem?*

Have you taken immunosuppressive, other steroids, or anticancer drugs, or have you had radiation treatments?*

During the past 12 months, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

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?*

Have you received any vaccinations in the past 4 weeks?*

For women: Are you pregnant or is there a chance that you could become pregnant during the next 30 days?

For women When was the first day of your last menstrual period

Date

I have read, or had explained to me, the information sheet about the administered vaccination.
I understand that if my vaccine requires two doses, I will need to be administered (given) two doses to be considered fully vaccinated.
I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions
I understand the benefits and risks of the vaccination as described. I request that the mentioned vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent
I understand THAT I WILL BE ULTIMATELY RESPONSIBLE FOR ANY CHARGES if I am not a covered person under the insurance plan (program listed above), the services are not covered services, or any co-pays, deductibles or coinsurance obligations apply.
I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
I GIVE CONSENT to PARK RIDGE PHARMACY and its staff to vaccinate me with this vaccine.
I GIVE CONSENT to PARK RIDGE PHARMACY and its staff to communicate with me via text, email and or phone for any updates

Vaccine Recipient Name*

First NameLast Name

Vaccine Recipient, Surrogate/Guardian Signature*

Vaccination Date*

Date

Vaccination Time*

Hour Minutes

AM/PM Option

Relationship to Patient if other than recipient*

Select the vaccine*

RPh Name

Signature

DateTime

Date

Take Photo of ID

Take Photo of Insurance Card

Take Photo of Medicare Part B

For better serving you, do you have any other notes, special requests, and/or comments you need your pharmacist to know