Registration Form for Shingles Vaccine
PATIENT Details:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
Insurance Information
Name of Insurance Provider
*
Policy/ID Number
*
Pharmacy Plan Name
*
Medicare Number (Red/White/Blue Card) - if no Medicare Number enter "0"
Vaccination Required
Appointment
*
SCREENING HEALTH QUESTIONS
Please answer the following questions, thank you.
Are you sick today?
*
Yes
No
Do you have allergies to medications, food, a vaccine component, or latex?
*
Yes
No
If yes, please specify:
Have you ever had a serious reaction after receiving a vaccination?
*
Yes
No
If yes, please specify:
Does the patient have a history of Guillain-Barré Syndrome (GBS)?
*
Yes
No
Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?
*
Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
*
Yes
No
Do you have a parent, brother, or sister with an immune system problem?
*
Yes
No
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?
*
Yes
No
Have you had a seizure or a brain or other nervous system problem?
*
Yes
No
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
*
Yes
No
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
*
Yes
No
N/A
Have you received any vaccinations in the past 4 weeks?
*
Yes
No
If yes, please specify which vaccine:
Please sign for vaccine consent and to upload vaccine to CAIRS:
*
Submit
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