Shingles (Herpes Zoster) Immunization Vaccine Administration Form

Name

First NameLast Name

Date of Birth

Date

Age

Gender

Phone Number:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Details: (Fill this Section only if you haven't previously filled prescriptions with us)

Insurance Plan Name

ID #

BINPCN

RX Group #

Primary Care Provider / Doctor :

Full NamePhone

Do you currently feel sick?

Are you 50 years old or older?

Have you had Chicken Pox as a child?

Do you have any health conditions (e.g. diabetes, heart diseases, asthma, etc.)?

Please list the health conditions if any here:

Have you received a Shingles vaccine before?

Have you had a reaction to a vaccine before?

What was the reaction?

Do you have any allergies to medications or foods?

Please list the allergies to medications or foods

Are you allergic to thimersol?

Are you currently pregnant or breastfeeding?

Do you currently have Shingles?

Please read carefully and sign below.

I, the undersigned, have read or had explained to me the vaccine information sheet (VIS). I understand that it is not possible to predict all side effects or complications associated with receiving vaccination I understand the risks and benefits associated with the vaccine and have had any questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the aforementioned person for whom I am authorized to make this request. I understand that my vaccination will be submitted NYSIIS (New York State Immunization Information System) unless otherwise stated.
I acknowledge that a pharmacist or certified pharmacy intern will be administering the vaccine.

Signature

Print Name

First NameLast Name

Date

Appointment

Shingles (Herpes Zoster) Immunization Vaccine Administration Form

Please answer the following questions. They will help us determine your eligibilty to receive a vaccination today.