Travel Vaccine Appointment Template

Vaccine Administration Record Professional Pharmacy 9106 Philadelphia Rd # 100 Rosedale, MD 21237-4331

Name of person receiving vaccination*

Appointment*

What gender does your insurance company identify you as?*

MaleFemale

Date of Birth*

Date

Address

Street Address Line 2

CityState

Zip

What is your phone number?*

Do you have any allergies to medication or other products? If so, please list them below:

What is your race?

Who is your primary care provider?

What is your primary care doctor's fax number, if available?

What is your mother's maiden name?

What is your email address?

example@example.com

Are you sick today?*

YesNo

Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?*

YesNo

Have you ever had a serious reaction after receiving a vaccination?*

YesNo

Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*

YesNo

Do you have a long-term health problem such as heart disease, lung disease, gastrointestinal disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes) anemia, or other blood disorder?*

YesNo

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, thymus disease, Crohn's disease, herpes, or cold sores?*

YesNo

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?*

YesNo

Have you had a seizure, brain or other nervous system problem or Guillain Barre?*

YesNo

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)?*

YesNo

For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNo

Have you received any vaccinations or TB skin test in the past 4 weeks?*

YesNo

Do you have a history of fainting, particularly with vaccines?*

YesNo

For patients receiving Tdap Vaccination: Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?

YesNo

For patients receiving Hepatitis A or B Vaccination: Have you had a past reaction to neomycin, latex or yeast?

YesNo

Consent

I have read, or have had read to me, the written information regarding the vaccine(s) I will be receiving. 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 have received a copy of current Vaccine Information Sheet. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Professional Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Professional Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccines.

I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Signature*

Date*

Date

Which vaccine (s) do you plan on receiving?*