2024 Pre-Vaccination Questionnaire (COVID/Flu)

2024 Pre-Vaccination Questionnaire (COVID/Flu)

Please complete this form for each person receiving a vaccine- once you click submit please refresh the page, and recomplete the form for any additional children. Please ensure that you see a confirmation page each time you submit the form, and receive a confirmation email for each form submission.
You MUST carefully complete this form.

All data fields are important, including the date and location of your scheduled appointment.

Once submitted, errors cannot be corrected and you will need to complete the form online again.
Are you completing this form for child (or 18+ pediatric patient) or as a parent?*

Parent Vaccination (Not Currently Offered)Child OR 18+ Pediatric Patient
Date of Scheduled Vaccination Appointment:*

MonthDayYear
Date
Location of vaccine appointment:*
Patient Information
Name of Patient*

First NameLast Name
Date of Birth*
Flu and COVID vaccines are only available for children 6 months of age and older.
Choose the patient's age group:*

6 months- under 5 years5 years - under 12 years12 years and up
Is this person receiving a COVID19 Shot? (Available for children only)*

YesNo

Flu Prevaccination Screening: Adult
1. Have you ever had a serious reaction to a previous dose of influenza vaccine, or hada life-threatening allergy to any ingredient in the vaccine?*

NoYes
2. Have you ever had a serious reaction to a previous dose of influenza vaccine, or had a life-threatening allergy to any ingredient in the vaccine?*

NoYes
3. Are you over the age of 65?*

NoYes
4. Have you had a fever or moderate or severe illness in the past 2 days?*

NoYes

Consent and Acknowledgment
A copy of a Vaccine Information Sheet or a fact sheet has been provided to me corresponding to the vaccine that I will receive. I have read the information and I have had the opportunity to ask questions and by which answers were given to me to my satisfaction. I understand that the vaccine has corresponding benefits and risks and I assume full responsibility for its effect or reaction to my body.

I request that the vaccine be given to me or to the above-named patient for whom I am authorized. I have been advised and I understand that I have to remain within the premises for 15 minutes after I have been administered the vaccine.

I understand that in case side effects start to manifest, I shall call my doctor, the pharmacy, and/or 911.

I understand that my health information may be required to be disclosed to the physician responsible for this protocol of gathering information of people vaccinated (if applicable) for the benefit or use of my insurance plan, health services, medical facilities, my physician, federal registries, for the purpose of this and other procedures or treatment. I also understand that this disclosure shall be limited to as previously stated and shall not be used for other purposes not authorized by me.
Representation*

I am signing this form in my own full capacity.I am the authorized legal guardian/representative of the above-named patient. I am signing this form as an express giving of my consent for and on behalf of the patient.
Name of Adult patient/Legal Guardian completing Form*

First NameLast Name
var 1 (do not delete)
var 2 (do not delete)
var 3
date field 1

MonthDayYear
Date
date field 2

MonthDayYear
Date
date field 3

MonthDayYear
Date
Parent Email
example@example.com
Should be Empty:

2024 Pre-Vaccination Questionnaire (COVID/Flu)

Consent and Acknowledgment