Yellow Fever Vaccine Registration

Yellow Fever Vaccination Registration Form

Please complete the entire form to schedule your Yellow Fever vaccination appointment. Boone Drug takes your personal information seriously. This form is 100% HIPAA compliant.
Date of Submission:

MonthDayYear
Date
Select your appointment date and time:*
Appointment Date

MonthDayYear
Date
The Yellow Fever Vaccine is valid on the 10th day after administration. Given your current appointment date, your vaccine will be valid on:
Start Time

Hour Minutes

AM/PM Option
Appointment End Time Added
End Time

Hour Minutes

AM/PM Option
The Yellow Fever Vaccine is valid on the 10th day after administration. Given your current appointment date, your vaccine will be valid on:
Your Name (EXACTLY AS IT APPEARS ON YOUR PASSPORT):*

First NameMiddle initial or NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Age
WARNING: Please be aware that individuals 60 years of age and over are at an increased risk of the more severe side effects associated with the yellow fever vaccine. These serious adverse events (vaccine associated neurologic disease (YEL-AND) and vaccine associated viscerotropic disease (YEL-AVD)) occur at a rate of 0.8 cases (YEL-AND) and 0.3 cases (YEL-AVD) for every 100,000 doses of YF vaccine distributed but these rate increases when looking at individuals 60 and over to 2.2 cases for every 100,000 doses distributed for YEL-AND and 1.2 cases for every 100,000 doses distributed for YEL-AVD.

Please discuss with your primary care provider the risks vs the benefits of receiving the yellow fever vaccine as it pertains to your personal health and medical history.
Acknowledgement of Age Associated Risk

I acknowledge that my age puts me at increased risk for severe side effects when receiving the Yellow Fever vaccine. I accept these risk and wish to receive the vaccine.
Gender*

MaleFemalePrefer not to discloseOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Maiden Name*
We use this information to update your immunization registry records.
Mother's First Name*
We use this information to update your immunization registry records.
Do you have a primary care provider (family doctor)?*

YesNo
Primary Care Provider Info

NameCityState
Health Information

Please complete all questions below.
Have you ever received a yellow fever vaccine before?*

YesNo
PLEASE NOTE: If you have received a previous dose of the yellow fever vaccine, current recommendations are that a single dose of the yellow fever vaccine is sufficient for lifetime protection with very rare instances in which a booster dose is recommended. It is our facility's understanding that existing ICVP (yellow cards) with the 10-year validity listed will be accepted and valid as long as the certificate itself meets validity requirements under International Health Regulations (for example the card is still legible and your legal name has not changed) and should not need to be re-issued.

If you have misplaced your ICVP (yellow card), it can be reissued by the clinic you received your initial yellow fever vaccine from.
What was the date of your last yellow fever vaccine?

MonthDayYear
Date
I have misplaced my previous ICVP and I am unable to contact the clinic that issued it to request a replacement:

YesNo
Were you pregnant at the time of your last yellow fever vaccine?

YesNo
Have you received a hematopoietic stem cell transplant since your last yellow fever vaccine?

YesNo
Are you HIV positive?

YesNo
Did you have an allergic reaction to your previous yellow fever vaccine?

YesNo
Have you received a vaccine or a TB skin test in the past 30 days or are planning to receive a vaccine or TB skin test in the next 30 days?*

YesNo
If yes, which vaccines and when?
Vaccine names
Are you severely allergic to eggs or any component of the yellow fever vaccine?*

YesNo
Has a physician or other healthcare professional every cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a doctor's office or hospital setting or have you ever had a reaction to any previous vaccinations?*

YesNo
If yes, please explain:
Are you currently pregnant or planning to become pregnant in the next 3 months?*

YesNoNot Applicable
The Yellow Fever Vaccine is a live vaccine. Live vaccines are NOT RECOMMENDED for individuals who are pregnant or may be pregnant. If you are currently trying to conceive, please confirm that you are not pregnant before receiving the vaccine.

I can confirm that I am not currently pregnant.
Are you currently breastfeeding?*

YesNoNot Applicable
Have you been diagnosed with HIV?*

YesNo
If yes, are you considered currently symptomatic or have a CD4+ T-lymphocyte count of less than 200/mm^3?

YesNo
Have you ever been diagnosed with a thymus disorder? (Including: myasthenia gravis, DiGeorge Syndrome, thymoma, or thymectomy)*

YesNo
Have you ever received an organ transplant? (Including: bone marrow transplants in the past 2 years or any solid organ transplant)*

YesNo
If yes, when did the transplant occur?

MonthDayYear
Date of transplant
Are you still taking immunosuppressive drugs related to the transplant?

YesNo
Have you ever been diagnosed with an immune deficiency or cancer?*

YesNo
If yes, please elaborate on the condition (including the name of the condition and any current or recurrent treatments):
If yes, are you currently on any immunosuppressive therapies? (This includes but is not limited to: alkylating agents, TNF- α inhibitors, interleukin blocking agents, monoclonal antibodies targeting immune cells, and long term (>14 days), high dose, oral corticosteroids):

YesNo
Have you currently or recently received radiation therapy?*

YesNo
Do you have any additional medical conditions not covered above? (If not, answer N/A or Not Applicable):*
List of medical conditions
Please list all medications you are currently taking (including any over the counter medications or supplements, if none, answer N/A or Not Applicable):*
List of medications
Please list any allergies or reactions to medications, food, vaccines, insects, etc (If none, answer N/A or Not Applicable):*
List of medications
Travel Itinerary

Please complete the following questions, if any changes are made to your itinerary after completing this form and before you attend your appointment, please bring those changes with you to your appointment.
Departure date from the United States:*

MonthDayYear
Date
Return date to the United States (if applicable, if undeterminded leave blank):

MonthDayYear
Date
Accommodations while travelling:*

Hotels with air conditioningHostels with screeningTentLocal housing or apartmentsUnknown or varied
If you answered “unknown or varied” please provide any details regarding your accommodations that you currently have:
Please list ALL countries and regions in order of travel. Include any layovers in countries of South America, Africa, or Panama.*
Countries list:
One or more of the countries on your itinerary REQUIRES proof of a VALID yellow fever vaccination for all individuals entering the country. Based on your appointment selection, your vaccination will be valid on: {theYellow211}

Please make sure that your arrival date to any of the countries listed below is ON OR AFTER the date your vaccine will be considered valid:
- Angola
- Benin
- Burkina Faso
- Burundi
- Cameroon
- Central African Republic
- Congo, Republic of the
- Cote D'Ivoire
- Democratic Republic of the Congo (DRC)
- Gabon
- Ghana
- Guinea
- Guinea-Bissau
- Mali
- Niger
- Sierra Leone
- South Sudan
- Togo
- Uganda
- French Guiana
Are you receiving this vaccine for work?

YesNo
If yes, please list your employer:
Informed Consent

I certify that I am: (i) the patient and at least 18 years of age, or (ii) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Boone Drug, Inc. to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccination(s) and recognize the risks and benefits associated with the vaccine(s). I acknowledge that I have received, read, and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have chosen to receive. I authorize this vaccination information to be reported to my primary care provider (if available) and the State immunization registry.
I agree to bring my passport and a copy of any updates to my travel itinerary to my vaccine appointment.
I understand that I am expected to wait in the vaccination area for at least 15 minutes after receiving my vaccine.
I understand that this request is for the yellow fever vaccine only, and that I should seek out a full travel consult for a complete set of recommendations for my trip including malaria prophylaxis medications, necessary maintenance medications for the duration of my travels, and any other vaccinations or medications that might be indicated for the location(s) I am visiting.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Yellow Fever Vaccination Registration Form

Health Information

Travel Itinerary

Informed Consent