• Prevnar 20 Pneumonia Vaccine Administration Form

  • Date of Birth*
     - -
  • Gender*

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

  • Do you currently feel sick?*
  • Do you currently have a fever?*
  • Do you have any health conditions (e.g. diabetes, heart diseases, asthma, etc.)?*
  • If you are under 65 years old, Do you have any chronic health conditions or autoimmune disorder?*
  • Have you received only one pneumonia vaccine before?*
  • If YES to the last question, Was your last vaccine over 1 year ago?
  • Have you received 2 different pneumonia Vaccines before?*
  • If YES to the last question, Was your last vaccine over 5 years ago?
  • Have you had a reaction to a vaccine before?*
  • Do you have any allergies to medications or foods?*
  • Are you allergic to thimersol?*
  • Are you currently pregnant or breastfeeding?*
  • Have you ever had Guilain- Barre Syndrome?*
  • Do you have a blood-clotting disorder?*
  • Are you taking any blood-thinning medications?*

  • 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 under a pharmacists supervision will be administering the vaccine.

  • Date*
     - -
  • Appointment*
  • Should be Empty: