Flu Shots In-Pharmacy Sept 2023

In-store FLU Shots

Registration

FLU (seasonal 2023) Vaccine

Flucelvax Quadrivalent for UNDER 65 years of age

or

FLUAD+65 Quadrivalent for OVER 65 years of age

IMPORTANT:

Thank you for chhosing Fairmount Pharmacy for your pharmacy's vaccination needs. We look forward to the opportunity to serve members of our community.

Completing this form will allow you to schedule a seasonal FLU VACCINE appointment to receive:

Flucelvax Quadrivalent vaccine (under 65 years)

or

FLUAD +65 Quadrivalent vaccine (over 65 years)

from staff of:

Fairmount Pharmacy

at

1900 Green Street

Philadelphia, PA, 19130

PLEASE BRING YOUR INSURANCE CARD AND ID.

PLEASE WEAR SHORT SLEEVES FOR EASE OF ACCESS TO INJECTION SITE.

We look forward to seeing you!

Appointment*

Vaccine Recipient First Name*

Vaccine Recipient Last Name*

Gender*

Date of Birth*

Date

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I authorize Fairmount Pharmacy to bill my PRESCRIPTION (not Medical) insurance for the cost of the FLU shot and administration. I also accept responsibility for any copayment due on my part payable to Fairmount Pharmacy and will pay any copayment upon receipt of pharmacy bill from Fairmount Pharmacy.*

YES

Social Security Number. PLEASE NOTE-This form is HIPAA Compliant and encrypted for your security. Fairmount Pharmacy uses your SSN to determine insurance coverage ONLY and does not share your information. Should you wish not to provide, please be sure to bring in your CURRENT Prescription insurance information at the time of your appointment.

In which arm would you like to receive your vaccine?*

Left ArmRight Arm

Please indicate which vaccine you wish to receive at your appointment. Please be sure to choose the correct FLU Shot based on your age.*

Flucelvax Quadivalent Flu vaccine for Ages 9 and olderFLUAD Quadivalent Flu vaccine for Ages 65 and older

Vaccine Recipient Phone Number

Cell phone preferred.

E-Mail Address

Race*

Ethnicity*

Emergency Contact Name

Relationship to Emergency Contact

Phone Number of Emergency Contact

Please enter a valid phone number.

If patient is a minor, please complete the following.

Parent/Guardian First NameParent/Guardian Last Name

Please answer "Yes" or "No" to the questions below concerning your Medical History. To save time in-person, we ask these questions now.*

	YES	NO
Do you have allergies or reactions to any foods, meds, vaccines, or latex? (Ex:eggs, gelatin, neomycin, thimerosol, etc.) or have you ever had a severe allergic reaction (ex:anaphylaxsis) to something? For example: a reaction for which you were treated with epinephrine (Epi-Pen) or for which you had to go yo the hospital? if yes, what are you allergic to?
Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularly with vaccines? Has any physician or any other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
Have you had a seizure or a brain or other nervous system problem or Guillain Barre Syndrome?
Have you ever had a severe allergic reaction after receiving a vaccine?
Do you have a history of myocarditis (inflammation of the heart muscle), pericarditis (inflammation of the lining around the heart), multisystem inflammatory syndrome (MIS-C or MIS-A), or thrombocytopenia syndrome (TTS)? Do you have a bleeding disorder or take blood thinners such as Warfarin/Coumadin?
Are you moderately or severely immunocompromised from a medical condition/immunosuppressive therapy, including but not limited to: active treatment for solid tumor/hematologic malignancy, solid organ/stem-cell transplant, primary immunodeficiency syndrome, advanced/untreated HIV infection, or active treatment with high dose corticosteriods/other immunosuppressive/immunomodulatory biologic agents?
Are you pregnant or do you plan on becoming pregnant in the next 30 days?

Consent (check each box below after reading and prior to signing the form*

	Check each box
I understand the benefits and risks of the 2023 FLU vaccine as described in the Fact Sheet (found in link above). I request the vaccine to be given to me.
I agree to stay in the vaccine administration area after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the 2023 FLU vaccine and may incur a cost (copayment) for the FLU vaccine.

PLEASE RECORD THE DATE AND TIME OF YOUR APPOINTMENT PRIOR TO SUBMITTING THIS FORM!

YOUR CONFIRMATION WILL NOT HAVE THIS INFORMATION.

Signature of Person to Receive Vaccine & VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Clear

Date Signed*

Date