Vaccines (Form A)

Vaccine

ADMINISTRATION RECORD AND SCREENING
Information collected on this form will be used to document authorization for receipt of vaccines. The information will be shared through the Wisconsin Immunization Registry (WIR) with other health care providers directly involved with the patient to assure completion of the vaccine schedule. Information collected on this form is voluntary and confidential.
PERSONAL INFORMATION
Full Name*
Date of Birth*

MonthDayYear
Date
Age calculated (in years)
Address*

Address

Street Address Line 2

City StateState / Province

Zip
Phone*
Email (optional)
example@example.com
Are you sick today (for example: a cold, fever, acute illness)?*

YesNoDon't know
Do you have allergies to medications, food, or any vaccine (for example: eggs, gelatin, neomycin, Thimerosal, latex, etc)?*

YesNoDon't know
Please list above mentioned allergy:
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

YesNoDon't know
Have you received another vaccine in the past 14 days?*

YesNoDon't know
Choose the vaccine(s) you would like to receive

Shingles (Shingrix)Pneumonia (Prevnar 20)Tetanus/Diptheria (TDAP)
Choose the vaccine(s) you would like to receive

Shingles (Shingrix)Pneumonia (Prevnar 20)Tetanus/Diptheria (TDAP)
Have you EVER had an RSV vaccination before (regardless of when)?*

YesNo
Good news! You do not need any additional vaccinations for RSV! Since you've already received one, you are covered for your lifetime!

You will not be receiving an RSV vaccine in this visit.
Consent for services, HIPAA Privacy Information, and Medical Records:

I have been provided with the Vaccine Information Sheet (VIS) and /or have been provided with information regarding the vaccine I am receiving. I understand all the benefits and risks of the vaccine and have had the chance to ask questions regarding it. I voluntarily assume full responsibility for any reactions that may result. I request the vaccine be given to me and authorize and direct this health care provider to use or disclose my health information to my Primary Care Physician (PCP), my insurance plan and/or state federal registries, where required for purposes of treatment, payment or other health care operations. This only allows this provider to disclose the following medical records: only documents related to the vaccination received today.
Signature*

Clear
Date

MonthDayYear
Date
Insurance/Billing Consent:

To the best of my knowledge, the insurance and billing information I have supplied to this provider is accurate. In the case of a denied claim, I understand I will be billed for the vaccine and any fees associated with administering the vaccine. For Medicare Billing: I authorize this providerto release information and request payment. I understand that the information given by me in applying for payment is correct. I authorize the release of all records to act on this request and I request that payment of benefits be made on my behalf.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Vaccine

PERSONAL INFORMATION