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)
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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