Travel Vaccine Appointment Template

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

  • Appointment*
  • What gender does your insurance company identify you as?*
  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Are you sick today?*
  • Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?*
  • Have you ever had a serious reaction after receiving a vaccination?*
  • Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*
  • 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?*
  • 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?*
  • 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?*
  • Have you had a seizure, brain or other nervous system problem or Guillain Barre?*
  • 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)?*
  • For women: Are you pregnant or is there a chance you could become pregnant during the next month?
  • Have you received any vaccinations or TB skin test in the past 4 weeks?*
  • Do you have a history of fainting, particularly with vaccines?*
  • For patients receiving Tdap Vaccination: Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?
  • For patients receiving Hepatitis A or B Vaccination: Have you had a past reaction to neomycin, latex or yeast?

  • 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.

  • Date*
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  • Which vaccine (s) do you plan on receiving?*
  • Should be Empty: