VAR - Chinook

Name*

First NameLast Name

Gender at Birth*

MaleFemale

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Allergies*

Are you sick today?*

YesNo

Do you have allergies to medication, food, eggs, yeast, a vaccine component, or latex?*

YesNo

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

YesNo

Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*

YesNo

Do you have a long term health problem such as heath disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?*

YesNo

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, herpes, or cold sores?*

YesNo

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

YesNo

Have you had a seizure or a brain or other nervous system problem or Guillain Barre?*

YesNo

During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug?*

YesNo

Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNo

Have you received any vaccinations or TB skin test in the past 4 weeks?*

YesNo

Do you have a history of fainting, particularly with vaccines?*

YesNo

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have a received a copy of a current VIS. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Chinook Health, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certrify that I am at least 18 years old and hereby give my consent to the pharmacists of Chinook Health to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Signature*

Upload a picture of ALL insurance cards (medical, pharmacy, etc).*

Offsite Administration Location

Flulaval Site of Injection

LDRD

Flulaval Lot Number

Flulaval Expiration Date

Flulaval NDC Number

Fluad Site of Injection

LDRD

Fluad Lot Number

Fluad Expiration Date

Fluad NDC Number

Spikevax Site of Injection

LDRD

Spikevax Lot Number

Spikevax Expiration Date

Spikevax NDC Number

Notes: