Temple Israel Influenza and COVID-19 Vaccine Clinic Sep 24, 2024

This is an Influenza and COVID-19 vaccination clinic being held in Temple Israel by Crestwood Pharmacy on September 24, 2024.

Please fill out this Immunization Screening and Consent Form for your dose of the Flu and Moderna COVID-19 2024-2025 Vaccines.

This form is for the Moderna Vaccine. Please continue only if you have completed your primary series.

Please review Influenza Vaccine Information Sheet (VIS) and COVId-19 Vaccine Information Sheet (VIS)

Appointment times may be subject to change based on availability

Thank you for your cooperation!

First Name*

Last Name*

Please select which vaccine you would like to receive*

Spikevax (Moderna COVID-19) VaccineInfluenza (Flu) VaccineBoth (COVID-19 and Flu)

Address*

Address Line 1

Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Please enter a valid phone number.

Sex at Birth (M/F)*

Date of Birth*

Date

Age*

Email (enter to receive completion confirmation)

example@example.com

Race*

Ethnicity*

Pharmacy Insurance Name*

Insurance ID. If you have Medicare (red, white, and blue card) please enter Medicare ID or last 4 digits of SSN*

Insurance BIN Number

Are you feeling sick today?*

YesNo

In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?*

YesNo

Do you have allergies to medications, food (eggs or dairy), a vaccine component, or latex? If Yes please list below*

YesNo

If answered yes above please state what you are allergic to or type N/A if none*

Have you ever had a serious reaction after receiving a vaccine?*

YesNo

Was your last COVID-19 Vaccine (any type) over 2 months a go?*

YesNo

Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorders?*

YesNo

Do you have cancer, leukemia, HIV, AIDS or any other immune system problem*

YesNo

For Women, Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNo

Have you ever had Guillain-Barre Syndrome?*

YesNo

Do you have a blood-clotting disorder or take blood thinning medications?*

YesNo

Have you experienced any blood clotting issues from a previous vaccine?*

YesNo

Do you weigh more than 33 pounds? (We cannot administer the Flu Vaccine if your child is under 33 pounds. Please contact their pediatrician to schedule your child's Flu Vaccine)*

YesNo

Time Slot*

Immunization Agreement
I understand that the pharmacy advises me to remain least 15 minutes after the injections for observation. I will notify the pharmacy of any adverse events associated with immunization. Permission is herby granted to Crestwood Pharmacy to release information to my primary care provider, identified above, regarding any vaccinations received today.

NYSIIS Reporting
Our Pharmacy and the New York State Department of Health want to inform you about the Statewide Immunization Information System(IIS) By law, any immunizations given to patients under the age of 19 must be reported into a secure web-based IIS and this electronicsystem is Called the New York State Immunization Information System (NYSIIS).For patients aged 19 and older, immunizations may be reported to NYSIIS with patient consent. Inclusion of adults will significantly contribute to a fully-developed, population-based database of accurate immunization records, and complete date is essential to developing statewide immunization programs intended to reduce the burden of vaccine preventable disease.

By signing below, I agree to the reporting of my vaccine administration to NYSIIS

Signature*