Abrysvo (RSV) Intake/Screening

CDC is recommending pregnant women 32 to 36 weeks gestation, or patients over the age of 60 with certain health conditions get vaccinated against Respiratory Syncytial Virus. If you are unsure if you should be vaccinated please contact your primary care provider or speak with a pharmacist at (617) 876-4868.

Please select one of the following options*

I am over the age of 60I am a MALE or a non-pregnant female, 59 years old or youngerI am a PREGNANT FEMALE between 32 and 36 weeks gestation and I will be scheduling an appointment during the months of September through January

Based upon your answers, you are not eligible to receive this vaccine at Inman Pharmacy. We suggest you contact your primary care provider to determine if they are able to administer the vaccine to you.

Name*

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Address*

Street Address

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Date of Birth*

Date

Gender at Birth*

Race*

Ethnicity*

The following questions will help us determine if there is any reason we should not give you the RSV vaccine today. If you answer yes to any question it does not necessarily mean you should not be vaccinated, it just means additional questions must be asked.

Are you feeling sick at all today?*

YesNo

Please indicate if you are allergic to any of the following:*

	YES	NO	UNSURE
Medications
Food
Vaccine component
Latex

If you answered yes to any of the allergy questions above, please list your allergies and the reaction:

Do you have a bleeding disorder or are you taking a blood thinner?*

YesNo

Have you ever had Guillain-Barre Syndrome?*

YesNo

Have you ever had a serious reaction to a previous vaccine?*

YesNo

Which vaccine did you previously react to and what was the reaction:

In the past 3 months have you taken medications that affect your immune system such as cortisone, prednisone, other steroids; anti-cancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments?*

YesNoUnsure

Have you received any vaccinations in the past 4 weeks?*

YesNoUnsure

If yes, please list your vaccinations here:

A vaccine, like any medication, is capable of causing serious problems such as severe allergic reactions, The risk of any vaccine causing serious harm, or death is extremely small. The most common side effects may include local symptoms like slight tenderness, redness, itching, or swelling at the injection site. Systemic symptoms are usually less common but may include fever, malaise, and muscle pain. Immediate presumable allergic reactions such as hives, angioedema, allergic asthma, or systemic anaphylaxis occur rarely after immunization. You will be monitored for immediate reactions following your immunization. Signs of an allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, or a fast heartbeat within a few minutes to a few hours following your immunization. If after you are allowed to leave the immunization area you develop a high fever, behavior changes, flu-like symptoms you should see your doctor right away.

Read each statement below and check each box to indicate you have read and understand.

	Check each box
I have read or had read to me the information regarding the RSV vaccine. I have received a copy of the Vaccine Information Sheet (VIS) for the vaccine being administered to me today (if you provided your email address this will be emailed to you or you may click this link at the end of the form to view online).
I had the opportunity to ask questions and if I asked any questions they were answered to my satisfaction. I understand the benefits and risks of the vaccine that is going to be administered to me. I further understand that while this vaccine may reduce my risk for contracting RSV, it is not guaranteed that I will not get the RSV.
I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from my receipt of the immunization administered.
I request this vaccine be administered to me during my scheduled appointment. I am releasing Inman Pharmacy, INC as well as its agents and employees from any and all claims arising out of, in connection with, or in any way related to my receipt of this immunization. Neither the pharmacy nor its agents or employees shall, at any time or to any extent whatsoever, be liable, responsible nor in any way accountable for any loss, injury, death, or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccine described above.
Massachusetts law (M.G.L.c 111, Section 24M) requires providers to report immunization information to a computerized immunization registry known as the Massachusetts Immunization Information System (MIIS). The MIIS stores immunization records for you and your healthcare provider and can help prevent outbreaks of disease like measles and the flu. All information in the MIIS is kept secure and confidential. The MIIS allows information to be shared with health care providers, school nurses, local boards of health, and stat agencies concerned with immunization. You have the right to object to the sharing of your immunization information across providers in the MIIS. If you wish to do so you will need to ask for an objection form. For more information you can visit the MIIS website at www.mass.gov/dph/miis or contact the Massachusetts Immunization Program directly at (617) 983-6800 or 888-658-2850.

Vaccine Information Sheet RSV 1-31-2025

Please choose only one option below*

I have insurance. By choosing this option I am authorizing Inman Pharmacy, INC to bill my pharmacy insurance to cover the vaccine and administration cost. I have uploaded a copy of my pharmacy benefit card. I understand the pharmacy may contact me to obtain additional information if necessary.I do not have insurance. I plan to provide payment to Inman Pharmacy INC, I will contact the pharmacy for pricing information.

MIIS Information Sheet

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Signature of Person to Receive Vaccine & VIS*

Date Signed*

Date

Abrysvo (RSV) Intake/Screening

RSV Screening Questions

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