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Comprehensive Immunization Screening & Consent Form
Please select your appointment time
*
Vaccine Recipient Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Age
*
Enter age of vaccine recepient
Gender
*
Please Select
Male
Female
Vaccine Recipient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email (Optional)
Vaccine Recipient Email (only if you want to receive a confirmation)
Vaccine Recipient Physical Address
*
Street Address
City
State Initials
Postal / Zip Code
Emergency Contact Name
*
Relationship to Emergency Contact
*
Phone Number of Emergency Contact
*
Format: (000) 000-0000.
Primary Care Provider
Insurance Information
Name of Primary Insurance (i.e., Wellmark, United Healthcare, Avera, Humana Part D, SilverScript Part D, AARP Part D, Tricare, VA etc.. Please indicate if it is a Medicare Part D plan.)
ID Number
RxBIN
RxPCN
RxGrp
Medicare Benefits Number
For Medicare Patients Only. Enter letters and numbers as shown in the image.
Select which vaccine(s) you would like to receive today.
*
Influenza (Fluarix 3 years to 64 years)
Influenza High Dose (Fluzone HD 65 years and older)
Pneumonia (Prevnar 20)
Shingles (Shingrix, must be 50 years and older, two shot series, 2nd dose in 2-6 months after first dose)
Tetanus/Whooping Cough (Boostrix)
RSV (Abrysvo, 75 years and older or 50-74 years at high risk)
COVID 19 (mNEXSPIKE 12 years and older)
Hepatitis B (Engerix-B)
Other
ALL Vaccine Screening Questions
*
Rows
Yes
No
1. Feeling sick today or moderate/high fever?
2. Allergic reaction to vaccine or vaccine component (i.e., eggs, latex, neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, polysorbate, polyethylene glycol, baker's yeast or yeast)?
3. Serious reaction after a previous vaccine?
4. History of Guillain-Barre Syndrome (GBS)?
5. Weakened immune system or taking immunosuppressive medication?
6. Bleeding disorder or taking a blood thinner?
7. Pregnant or planning pregnancy within the next month?
8. Received any vaccine within the past 4 weeks?
9. Ever fainted or felt dizzy after an injection or vaccine?
10. Had COVID-19 within the past 3 months?
11. Received a COVID-19 vaccine withing the past 6 months?
Which arm would like the vaccine administered?
*
Rows
Left
Right
Select Arm
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Enter ID number/Drivers License Number/Social Security Number
Enter one of the ID numbers in the box.
Name of Person Completing This Form
*
Relationship to Patient (if not patient)
By signing this form, I attest that all information I have provided on this form is true and accurate, thereby qualifying me to receive a COVID-19 vaccine/booster dose.
*
Date Signed
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Please click Submit, then click Sign Document in the blue box on the next screen.
Preview PDF
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