Immunization form All Vaccine

Vaccine Administration Record

All Vaccines are Provided by The Medicine Shoppe of Shillington PA (Reading PA area).
We make it easy for you to keep up with routine immunizations because we want you, your family, and everyone in the community to be at their best. Even though an appointment is not required, it’s preferred for faster service. We are able to vaccinate from ages 3 and older (Flu Shot is 3 year and old). Most vaccines are covered by majority insurance with as little as $0 Co-Pay.

Currently, we keep following vaccine in stock and any other vaccine needs to be ordered.
- Flu
- Pneumonia
- Shingrix
- Tdap (tetanus)
Are you customer of The Medicine Shoppe or ever been here before.*

YesNo
Select Your Desire Vaccine. If more than 1 vaccine then select either 1 of them. *
For Shingrix, Is is 1st or 2nd dose?*
Prevnar 20 eligibility:
- Vaccinated at least one year ago with Pnuemovax 23
- Never received a pneumonia vaccination or vaccination history is unknown and:
  - 65+ years of age
  - 19 to 64 years of age with conditions or risk factors listed by the CDC
Pnuemovax 23 eligibility:
- Vaccinated at least one year ago with Prevnar 13 or Vaxneuvance
Choose the Pneumonia option you need.*
Select an appointment time.*
Email*
example@example.com
Full LEGAL Name*
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Vaccine Recipient Phone Number*
Allergies
Race
Most insurances are covering for free up to 8 at-home COVID tests per month. Would you like to get At-Home COVID-19 OTC tests?

Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
5. 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?
6. 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?
7. 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?
8. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?
9. 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)?
10. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
11. Have you received any vaccinations or TB skin test in the past 4 weeks?
12. Do you have a history of fainting, particularly with vaccines?

For Tdap and adult Td: Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?*

YesNo
For Shingles: Have you had a past reaction to gelatin or triple antibiotic ointment?*

YesNo
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Clear
Date Signed ( We will ask for another signature on the day of vaccine)

MonthDayYear
Date
Should be Empty:

Vaccine Administration Record