Schedule an Immunization
We look forward to servicing you at Fisherville Pharmacy.
Select an appointment time below
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Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Are you are new patient?
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Yes
No
Which vaccines do you want to receive?
COVID-19
Influenza
Pneumonia
Shingles
Tdap (Tetanus, Diphtheria, Pertussis)
Which vaccines do you want to receive?
Influenza
Pneumonia
Shingles
Tdap (Tetanus, Diphtheria, Pertussis)
Screening Questions
Are you feeling ill today, or have you been ill within the last fourteen (14) days?
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Yes
No
Have you ever had a serious reaction after receiving a vaccine?
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Yes
No
Do you have allergies to medications, food, a vaccine component, or latex?
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Yes
No
Please specify any allergies or reactions.
Do you have a history of Guillain-Barré Syndrome, a neuromuscular condition?
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Yes
No
Do you have a bleeding disorder, or are you taking a blood thinner (warfarin, daily aspirin)?
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Yes
No
Have you taken antiviral medications in the past two (2) weeks?
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Yes
No
Have you received a vaccine in the past few four (4) weeks?
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Yes
No
Have you ever felt dizzy or faint before, during, or after a shot?
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Yes
No
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