General Vaccine Screening Form

Sparta Pharmacy Vaccine Intake

Patient intake for vaccination. Please complete the sections below.
1. Patient Information
Patient Name (if patient is a child, please enter the Child's Name)

First NameLast Name
Home Address

Street Address

Apt #

CityState

Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Gender
Gender
2. Vaccine Selection
Race

Other
Race
Ethnicity
Ethnicity
Phone Number
Format: (000) 000-0000.
Email
to receive PDF email of this form, not necessary to bring it (pdf password Vaccine#1
Last 4 digits of Social Security Number or Medicare Number
Which Vaccine are coming for today?
RSV Vaccine 65+ or 32 through 36 weeks gestational age of pregnancy
Which arm would you like to get the injection on
3. Health Screening
Pediatrician/Provider Name & Fax Number
We will fax record of vaccine to pediatrician for children
If you are getting the flu vaccine only, you may complete questions 1–4. If you are receiving any other vaccine, please answer all screening questions.
1. Is the person to be vaccinated sick today?
2. Does the person to be vaccinated have any allergies to medications, food, a vaccine component, or latex?
3. Has the person to be vaccinated ever had a serious reaction after receiving a vaccination in the past?
4. Has the person to be vaccinated ever had Guillain-Barré syndrome?
Skip questions 5–11 if you are only getting the flu vaccine.
5. Does the person have any long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
6. Does the person have cancer, leukemia, AIDS, or any other immune system problem?
7. Does the person take cortisone, prednisone, other steroids, or anti-cancer drugs, or have you had radiation treatments?
8. Has the person had a seizure or a brain or other nervous system problem?
If yes, please list
9. During the past year, has the person received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
10. For women: Is the person pregnant or is there a chance she could become pregnant during the next month?
4. Insurance & Uploads
11. Has the person received any vaccinations in the past 4 weeks?
12. Have you treated with antibody therapy specifically for COVID-19 (monoclonal antibodies or convalescent plasma)?
5. Consent & Signature
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
Please Upload Insurance Card (optional)

Cancelof
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Please Upload Supporting Uninsured Document

Cancelof
Patient signature (Parent or guardian, if minor):
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For minor, please provide Parent or Guardian's Full Name

First NameLast Name
Relationship to Patient
For minor, please provide Parent or Guardian's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history. I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools, licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3. I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department, or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number listed above. There is no cost to participate in this program.
New Jersey Department of Health Vaccine Preventable Disease Program / P.O. Box 369, Trenton, NJ 08625-0369 / 609-826-4860 (Fax 609-826-4866) / www.njiis.nj.gov / NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS) / CONSENT TO PARTICIPATE
Clinic-If we are coming to YOU, please select the Clinic below
1. Type BENECARD ID# if applicabletype ID#
2.On your HORIZON as Medical Insurance, please enter the ID Number on your card type ID#
3.Who is the Primary Cardholder?
first name/ last name
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Vaccine Manufacturer
Pharmacy Name
Registry ID Number
Parent/Guardian Name
Fax to
Pharmacy NPI
Do you have health insurance (not required for COVID vaccines):
By signing below I attest that I do not have any medical or pharmacy insurance. (optional)
Please upload a Photo ID such as driver license or passport copy if available. (By uploading your ID now will reduce your wait time in the pharmacy) Please also bring in original at time of vaccination (optional).

Cancelof
Please upload a picture of your prescription insurance card if available. (By uploading your insurance card now will also reduce your wait time in the pharmacy) Please also bring in original at time of vaccination (optional).

Cancelof
Calculation
Bring with you: PHOTO ID & INSURANCE CARD
After pressing SUBMIT, you are finished and will be redirected to a GOOGLE REVIEW page, and if you entered an email, will receive a copy of the Pre-Vaccination Checklist for your records.
Should be Empty:

Sparta Pharmacy Vaccine Intake

1. Patient Information

2. Vaccine Selection

3. Health Screening

4. Insurance & Uploads

5. Consent & Signature

Bring with you: PHOTO ID & INSURANCE CARD