SCOTT PHARMACY FLU 2023/2024

RSV Vaccine now available by prescription only, age 60+
New COVID Vaccine-Pending-Supply Mid-Oct possible
FLU SHOT PARKING LOT SCHEDULE: October 24-27th.

Section 1: Vaccine Recipient Information

Name: *

Date of Birth:*

Gender*

Age

Primary Healthcare Provider:

Address:*

Street Address (NO PO BOXES)

Street Address Line 2

CityState

Zip Code

Please select requested flu shot:*

High Dose Flu Shot (65+, Must have NO egg allergy)Flu Shot: (6+)

Section 2: FLU Pre Vaccination Assessment:

The following questions will help us determine if there is any reason you should not get the FLU vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain.

Please answer the following:*

	Yes	No	Don't know
1. Are you feeling sick today?
2. Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
3. Do you have allergies to a vaccine component, thimerosal, neomycin, or latex?
4. Do you have an egg allergy?
5. Do you have a weakened immune system caused by something, such as HIV infection or cancer, or do you take immunosuppressive drugs or therapies?
6. Have you ever had Guillain-Barre syndrome?
7. Are you pregnant or breastfeeding?

Please pick an appointment slot **PARKING LOT WEEK: 10/24/23 to 10/27/23:** *

We hope to have the updated Moderna COVID vaccine by October 15th. If available, would you like the Moderna COVID vaccine at the same time? At this time, the pharmacy will not be suppling Pfizer or other COVID vaccines.*

YesNo

Has it been less than 8 weeks since your last COVID vaccine?*

YesNo

Prescription insurance OR please bring your insurance card with you!:
ID #: RX BIN:
RX GROUP (GRP): RX PCN:

Signature:*

Clear

Section 3: Consent

I have read or have had explained to me the information provided in the Vaccine Information Statement (FLU VIS). I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of FLU vaccine and ask that the vaccine be administered to me or the person named above for whom I am authorized to make this request.

FLU Vaccine Consent Form