Pneumonia (Prevnar 19) Vaccine Administration form

Pneumonia (Prevnar 19) Vaccine Administration form
Crestwood Pharmacy 26A Picotte Drive Albany, NY 12208 (518) 435 - 2315

Please read the Vaccine Information Sheet Click Here

Please note appointment times may be subject to change depending on availability
Date*

MonthDayYear
Date
First Name*
MI
Last Name*
Date of Birth*

MonthDayYear
Date
Age*
Gender M/F*
Phone*
Home address*
City*
State*
Zip*
Insurance Plan Name*
ID
If you have Medicare please enter Medicare ID number or last four of SSN (type N/A if not applicable):*
BIN
PCN
RX Group
Primary Care ProviderDoctor Name
Primary Care Phone
1. Do you currently feel sick?*

YesNoUnsure
2. Do you currently have a fever?*

YesNoUnsure
3. Do you have any health conditions (e.g. diabetes, heart disease, asthma, etc.)*

YesNoUnsure
4.Are under 65 and have any chronic health conditions or autoimmune disorders?*

YesNoUnsureN/A (over 65)
If yes to the previous question please list below:
5. Have you received only 1 pneumonia vaccine (Prevnar 13 or Pneumovax) before?*

YesNoUnsure
6. If yes to the last question, was the last vaccine over 1 year a go?*

YesNoN/A
7. Have you received 2 pneumonia vaccines (Prevnar 13 and Pneumovax)*

YesNoUnsure
8. If Yes to the last question, was the last vaccine over 5 years a go?*

YesNoN/A
9. Have you had a reaction to a vaccine before?*

YesNoUnsre
If yes, what was the reaction?
10. Do you have any allergies to medications or food?*

YesNoUnsure
If yes, please list:
11. Are you allergic to thimersal?*

YesNoUnsure
12. Are you currently pregnant?*

YesNoUnsure
13. Have you ever had Guillain Barre Syndrome?*

YesNoUnsure
14. Do you have a blood-clotting disorder*

YesNoUnsure
Appointment*
Please read carefully and sign below. I, the undersigned, have read or had explained to me the vaccine information sheet (VIS I understand that it is not possible to predict all side effects or complications associated with receiving vaccination. I understand the risks and benefits associated with the pneumonia vaccine and have had any questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the aforementioned person for whom I am authorized to make this request.
Signature*

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Date*

MonthDayYear
Date
Print Name*
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