SCOTT PHARMACY FLU/COVID 2024/2025

Section 1: Vaccine Recipient Information

I have receive the Flu and / or COVID shot last year at Scott Pharmacy and my insurance information has not changed.

YesNo

Name: *

Date of Birth:*

Gender*

Age

Phone Number*

Please enter a valid phone number.

Address:*

Street Address (NO PO BOXES)

Street Address Line 2

CityState

Zip Code

Primary Healthcare Provider:

Please select requested shot(s):

Flu Shot: (6+)COVID - Moderna (12+)High Dose Flu (65+ and no egg allergy)

Section 2: Pre Vaccination Assessment:

The following questions will help us determine if there is any reason you should not get a 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?
8. For COVID: Have you received passive antibody therapy (monoclonal antibodies) as a treatment for COVID.
9. For COVID: Have you had a COVID Vaccine in the last 8 weeks.
10. For COVID: Have you tested positive for COVID in the last 90 days. If yes, you may have a better immune response if you wait 90 days from your positive date, but you still may receive it sooner based on personal risk of severe COVID and local levels of COVID.

Please pick an appointment slot:*

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

For Medication patients, please type in your Medicare Part B (Red/White/Blue Card) ID #:

Section 3: Consent

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

Signature:*

FLU / COVID Vaccine Consent Form