St. George 2024 Vaccine Clinic

'24-'25 Asti's South Hills Pharmacy Influenza Vaccine Assessment [St. George Church - Sunday 11/3 following Divine Liturgy]

PLEASE READ THE FOLLOWING QUESTIONS CLOSELY
*Please read all questions carefully*
Vaccine Recipient Name*

First NameLast Name
Social Security Number*
Gender at Birth*
Date of Birth*

MonthDayYear
Note: Certain vaccines have age restrictions
Age*
Vaccine Recipient Phone Number*
Primary Care Provider Name*
Emergency Contact Name
Emergency Contact Relationship to Vaccine Recipient
ie. Spouse, Mother, Father, Daughter, etc.
Emergency Contact Phone Number
Please enter a valid phone number.
What type of insurance coverage do you have?
Insurance Selection Helper

Based on your answer to the prior question, please attest to only one of the statements below:*

	Check One
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

For Medicare: Please upload a photo of your Medicare Card, the "Red White and Blue" Card. We do not need other insurance information.
For Commercial Insurance: Please upload a photo of your insurance card(s) here. You may have Medical Coverage that is different from your Pharmacy Coverage - please include a copy of BOTH cards. You can upload multiple pictures at a time! Front and Back of Cards is Necessary.
For Medicaid: Please upload a photo of your insurance card(s) here. You may have an Insurance Company Card, as well as an Access card. Please include a copy of BOTH cards. You can upload multiple pictures at a time! Front and Back of Cards is Necessary.
For Uninsured: Please upload a photo of your Driver's License or your State Identification Card. You can also upload a photo of your Social Security Card. You can upload multiple pictures at a time!
Cancelof
Having trouble uploading your card?
Insurance Plan Name*
ie. Highmark, UPMC, etc.
Insurance Member ID*
Primary Insurance Card
Insurance Group Number*
Primary Insurance Card
Which vaccine(s) are you scheduling? (select all that apply)*

Influenza (Flu Shot Age 3+)HD Influenza (Flu Shot Age 65+)

Vaccine Screening Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you received a vaccine within the last 4 weeks?
3. Are you allergic to any medication, latex, vaccine, or vaccine component?
4. Have you ever had a severe allergic reaction to anything, including medications, vaccines, food, environmental, etc.?
5. Do you have a weakened immune system caused by something such as HIV infection or cancer do you take immunosuppressive drugs or therapies such as: cortisone, prednisone, steroids, Humira, Enbrel, etc.?
6. Do you have a bleeding disorder or are you taking a blood thinner?
7. Are you pregnant or breastfeeding?
8. Do you have a history of Guillain-Barre Syndrome?

Additional Vaccines Administered

Date Administered and VIS Provided

MonthDayYear
Asti's South Hills Pharmacy is committed to helping our community overcome this pandemic. Our mission is 'To create lifelong relationships by bettering the lives of all we touch', and we view the opportunity provide you all with access to this critical vaccine as a privilege. Thank you for trusting in us as your pharmacy provider!
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'24-'25 Asti's South Hills Pharmacy Influenza Vaccine Assessment [St. George Church - Sunday 11/3 following Divine Liturgy]