Influenza Vaccine Form

1
Patient Information (Vaccine Recipient) All questions must be answered completely.
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Full Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date of Birth
Month
Day
Year
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Biological Gender* This field is required.
Please Select
Please Select
Male
Female
5
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number* This field is required.
Please enter a valid phone number.
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Phone Number Type* This field is required.
Home
Cellphone
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Mothers Maiden Name* This field is required.
9
State of Birth* This field is required.
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Email* This field is required.
example@example.com
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Ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
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Race* This field is required.
White
African American
Asian
Other
American Indian
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1. Are you feeling ill today, or have you been ill within the last 14 days?* This field is required.
Yes
No
Don't Know
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2. Have you ever had a serious reaction after receiving a vaccine?* This field is required.
Yes
No
Don't Know
15
3a. Have you ever had an allergic reaction to Polyethylene glycol (PEG)?* This field is required.(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing)
Yes
No
Don't Know
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3b. Have you ever had an allergic reaction to Preservatives such as thimerosal or phenol?* This field is required.(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing)
Yes
No
Don't Know
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3c. Have you ever had an allergic reaction to Polysorbate?* This field is required.(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing)
Yes
No
Don't Know
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4. Have you had Gullian-Barre Syndrome, a neuro-muscular condition?* This field is required.
Yes
No
Don't Know
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5. Do you have a bleeding disorder or are you taking a blood thinner (warfarin, daily aspirin)?* This field is required.
Yes
No
Don't Know
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6. Are you pregnant?* This field is required.
Yes
No
Don't Know
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7. Have you taken antiviral medications in the past 2 weeks [including: (zanamivir) Relenza®, (oseltamivir) Tamiflu, (peramivir) Rapivab, or (baloxavir) Xofluza]?* This field is required.
Yes
No
Don't Know
22
8. Have you received a vaccine in the past 4 weeks?* This field is required.
Yes
No
Don't Know
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8. Have you received a vaccine in the past 4 weeks? 9. Have you ever felt dizzy or faint before, during, or after a shot?* This field is required.
Yes
No
Don't Know
24
Consent:* This field is required.
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Fisherville Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Fisherville Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I understand that if I experience any side effects, it will be my responsibility to follow-up with my primary provider's office or at the health center of my choice. By authorizing the administration of the vaccine(s), I also authorize the release of this information to my primary care provider
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Patient signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
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New Hampshire Immunization Information System (NHIIS)* This field is required.New Hampshire Immunization Information System (NHIIS) is a secure, statewide, web-based system that connects and shares immunization information among authorized health clinics, health care provider offices, local health departments, schools, hospitals, and other health care facilities that administer immunizations and provide medical care to New Hampshire residents. NHIIS securely stores immunization records for all New Hampshire residents of all ages. New Hampshire Residents can either opt in or out of the system. Please select your preference. More information can be found on their website: https://www.dhhs.nh.gov/programs-services/disease-prevention/immunizations/nh-immunization-information-system/nhiis-0
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