2023 Gates Pharmacy - Vaccine Registration Form

Vaccine Registration Form

Flu - COVID- RSV - Shingles - Tetanus - Pneumonia
Which vaccine(s) would you want to receive today?*

FluCOVID (Moderna)COVID (Pfizer)RSVShinglesTetanusPneumonia
Appointment
Patient's First Name*
Patient's Last Name*
Date of Birth*

MonthDayYear
Date
Gender*
Address*
City*
State*
Zip*
Race
Ethnicity
Phone Number*
Emergency Contact Name*
Relationship
Phone Number*
Mother's Maiden Name*
Patient's State of Birth*
Primary Care Provider Name
If you would like for us to share your proof of vaccination with your primary care provider
PATIENT QUESTIONS
Are you feeling sick today?

NoYes
Do you have any allergies to medications, food (ie. eggs), latex, or vaccine components?*

NoYes
If "YES" to previous question (allergies), please list:
Have you ever had a serious reaction (including fainting) after receiving a vaccine?*

NoYes
Are you anxious about getting a shot today?*

NoYes
Do you have long-term health problems such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (diabetes), anemia, or other blood disorders?*

NoYes
Do you have cancer, leukemia, HIV/AIDs, or any other immune system problems? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, or Crohn’s disease?*

NoYes
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 treatment?*

NoYes
Have you had a seizure, or brain or other nervous system problems, or Guillain- Barre?*

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

NoYes
For WOMEN - are you pregnant or is there a chance you could become pregnant during the next month?*

NoYes
Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a physician’s office or hospital?*

NoYes
Have you received any vaccination in the past 4 weeks?*

NoYes
For Tdap or adult Td (ONLY). Do you have an open wound, puncture or tissue test that prompted you to get atetanus shot?

NoYes
I have read, or have had read to me, the written information regarding the vaccine(s) marked below. I have had the opportunity to ask questions that were answered tomy satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet for each vaccine Iam receiving today. I, on behalf of myself, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Gates Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in anyway related to the administration of the vaccine(s) marked below. If under 18 years old, signature by parent or guardian is required.

I AGREE TO WAIT NEAR THEVACCINATION LOCATION FOR APPROXIMATELY 15 MINUTES FOR OBSERVATION BY THE PHARMACY STAFF/PHARMACIST.
Patient Consent/Signature (or parent/guardian if patient is age 18 and under)*

Clear
Date of Consent*

MonthDayYear
Date
Please add an image of your health insurance card here:
Should be Empty:

Vaccine Registration Form

PATIENT QUESTIONS