Schedule an Immunization
We look forward to servicing you at Fisherville Pharmacy.
Select an appointment time below
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Name
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First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Date of Birth
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Month
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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
Consent
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 a health facility.
Signature
Date
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Month
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Day
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Date
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