RSV

Select an Appointment for an RSV Vaccine*

Date

Hour MinutesAM/PM Option

PERSONAL INFORMATION (please record your name exactly as shown on your insurance card)

Name

Gender

Age

Address

City

State

Zip

Phone Number

Area CodePhone Number

Email

example@example.com

Date of Birth

Date

Primary Doctor

Weight

Social Security # or Insurance ID #

Are you Sick Today?

Do you have any allergies to any vaccine components?

Have you ever had a serious reaction after receiving a vaccination?

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?

In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, anticancer drugs, or had radiation treatments?

During the past year, have you received a transfusion of blood or blood products, or been given a medication called immune globulin?

Have you received a vaccination in the last 4 weeks?

For women: Is it possible that you are pregnant or may become pregnant in the next three months?

I have read or have had explained to me the information in the vaccine information statement about the RSV vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the RSV vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request.

FOR MEDICARE & INSURANCE RECIPIENTS: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment.

Signature

Date