Immunization Administration Record, Screening Questionnaire and Consent
Full Name
*
First Name
Last Name
DOB
*
Gender
*
Male
Female
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Address
*
Address
Street Address Line 2
City
State
Zip Code
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Race
*
American Indian or Alaska Native
Native Hawaiian or Pacific Island
Black or African American
White
Asian
Other
Primary Care Provider Name
*
First Name
Last Name
Primary Care Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medicare Part B
Yes
No
Do you have any food/drug allergies?
*
Vaccine/Immunization Requested
*
Flu
Shingles
Meningococcal
Tdap
Pneumonia (PCV13 or PPSV23)
Hepatitis A
Hepatitis B
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Are you sick today?
*
Yes
No
Please explain:
*
Have you had a severe reaction to any vaccine?
*
Yes
No
Please explain:
*
Do you have allergies to medications, food (eggs), baker's yeast, thimerosal, streptomycin, neomycin or latex?
*
Yes
No
Please explain:
*
Are you pregnant or is there a chance you could become pregnant in the next month?
*
Yes
No
Please explain:
*
Have you had seizure disorder, brain disorder, neurological disorder or Gullian-Barre syndrome?
*
Yes
No
Please explain:
*
Do you have any other chronic health conditions like Asthma, diabetes or diseases of the heart, lungs or kidneys?
*
Yes
No
Please explain:
*
Have you had a pneumococcal or shingles vaccine?
*
Yes
No
Please explain:
*
Have you ever been vaccinated for Hepatitis A, B or started the series of Hepatitis A, B, or A & B?
*
Yes
No
Please explain:
*
Have you had a blood transfusion or received blood products such as immune globulin in the last year?
*
Yes
No
Please explain:
*
Have you received any vaccinations in the last 4 weeks?
*
Yes
No
Please explain:
*
Do you, or another member of your household, have cancer, leukemia, HIV/AIDS, or other immune system problems?
*
Yes
No
Please explain:
*
Are you currently on home infusions, steroid therapy, anticancer drugs or radiation treatment?
*
Yes
No
Please explain:
*
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I have read, or have had explained to me, the information regarding the vaccine(s)/immunizations(s) marked above. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and authorize the administration of the vaccine to me or the persons named below for who I am authorized to make the decision. I, for myself, my heirs, and executors release MediCenter Pharmacy as the Medicare provider, any retail or external site, physician, and employees, from any and all claims arising out of or in a way related to my receipt of this or these immunizations(s MediCenter Pharmacy and the aforementioned related parted shall not at any time or any extent be liable or responsible for any loss, injury, death or damage to be suffered or sustained at any time as a result of this vaccination program. I consent the release of this information to my Primary Care Physician as listed above to document receipt of vaccination. I agree to wait in the vaccination location for approximately 5 minutes for observation after the vaccination(s). Acknowledgement of Notice of Privacy Practices: I have received a notice of privacy practices. I understand that this document provides an explanation of ways in which my health information may be used or disclosed by MediCenter Pharmacy and of my rights with respect to health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Authorization
*
I authorize MediCenter Pharmacy to release information and request payment. I certify that the information given by me in applying for payment under Medicare is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf to MediCenter Pharmacy as my Medicare Part B Provider
Signature
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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