Shingles (Herpes Zoster) Immunization Vaccine Administration Form

Shingles (Herpes Zoster) Immunization Vaccine Administration Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemaleOther
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
Please answer the following questions. They will help us determine your eligibilty to receive a vaccination today.
Do you currently feel sick?*

YESNOUNSURE
Are you 50 years old or older?*

YESNOUNSURE
Have you had Chicken Pox as a child?*

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

YES, Please fill the blank below.NOUNSURE
Please list the health conditions if any here:
Have you received a Shingles vaccine before?*

YESNOUNSURE
Have you had a reaction to a vaccine before?*

YES, Please fill the blank below.NOUNSURE
What was the reaction?
Do you have any allergies to medications or foods?*

YES, Please fill the blank below.NOUNSURE
Please list the allergies to medications or foods
Are you allergic to thimersol?*

YESNOUNSURE
Are you currently pregnant or breastfeeding?*

YESNOUNSURE
Do you currently have Shingles?*

YESNOUNSURE
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*

Clear
Print Name*

First NameLast Name
Date*

MonthDayYear
Date
Appointment*
Should be Empty:

Shingles (Herpes Zoster) Immunization Vaccine Administration Form

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