Vaccine screening and appointment

Patient Name*
DOB*
Address*
City*
State
Zip Code*
Phone*
Email*
example@example.com
Do you have insurance?
Which vaccine do you want? (We have the following vaccines: COVID, FLU, Shingles, Tdap, Pneumococcal)
PHARMACY USE ONLY
Immunizer Name/Title/Signature

Clear
Date of Vaccination

MonthDayYear
Date
Does the patient authorize this pharmacy to report the administration of this immunization(s) to the Citywide Immunization registry (CIR)? Does the patient authorize this pharmacy to report the administration of this immunization(s) to their Primary Health Care Provider?

If there was any adverse reaction to the immunization(s) or if the vaccine was not administered, please document on the reverse side. Please remember to notify the patients Primary Health Care provider (if they have one) in the event of an adverse reaction or if the vaccine was not administered
Patient Signature

Clear
Date

MonthDayYear
Date
Appointment*
Should be Empty: