Immunization Screening Form 2023 v1

Which Vaccine will you be receiving today?

Select an appointment time*

Vaccine Recipient Name*

First NameMiddle NameLast Name

Vaccine Recipient Physical Address*

Street Address

Apt #

CityState Initials

Zip Code

Date of Birth*

Gender at birth*

Race*

Ethnicity*

Vaccine Recipient Phone Number*

Primary Care Provider Name

Emergency Contact Name*

Relationship to Emergency Contact

Phone Number of Emergency Contact*

Email

example@example.com

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3. Have you ever had an allergic reaction to Polysorbate?
4. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
5. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
6. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you received any vaccine in the last 14 days?
8. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
9. Has the person to be vaccinated ever had Guillain-Barré syndrome?
10. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
11. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
12. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
13. Do you have a bleeding disorder or are you taking a blood thinner?
14. Are you pregnant or breastfeeding?
15. ARE YOU TAKING ANY MEDICINES
16. ANY ALLERGY

Which arm would you like to get the injection on*

Left ArmRight Arm

Please input the numbers/letters from your Prescription Insurance card and if applicable, Medicare B Card, below. IF you have Medicare Part B through AETNA HMO, UNITED HEALTHCARE HMO (i.e. Verizon employees), or any other Part B, please put that card info below. You are looking at your prescription card if it has the letters RX on it otherwise, you are likely looking at your medical card. If your card does not have one of the below, please leave that field blank.

RX BIN:

RX PCN:

Member ID:

RX Group:

Last 4 Digits of Patient's SSN:

Medicare B # (red, white, blue card):

Please Upload Insurance Card

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Date Signed

Date

Pharmacist Name

First and Last Name

Pharmacist Signature

Immunizer Name

First and Last Name

Immunizer Signature

Lot Number

Pharmacy Name

Expiration Date:

Pharmacy NPI*

COVID-19 Vaccine Consent Form