2025-2026 Flu, COVID, RSV (Form V)

  • Flu/COVID/RSV Vaccine Administration Record and Screening

    Information collected on this form will be used to document authorization for receipt of vaccines. The information will be shared through the Wisconsin Immunization Registry (WIR) with other health care providers directly involved with the patient to assure completion of the vaccine schedule.  Information collected on this form is voluntary and confidential.
    • Patient Information 
    • Date of Birth*
       / /
    • Gender*

    • ATTENTION:
      You are {ageIn} years old.  Please only choose vaccinations that are approved for people {ageIn} years or older.  A pharmacist will review this form to confirm your vaccine eligibility.

    • Format: (000) 000-0000.
    • Do you have a Medicare Advantage plan?*

    • Please bring your Medicare Advantage plan card with you when you come to the pharmacy to receive your vaccination(s).

    • Which vaccine(s) did you schedule your appointment for?*
    • Screening Questions 
    • Are you sick today (for example: a cold, fever, acute illness)?*
    • Have you ever had an observed anaphylactic (severe allergic) reaction to a vaccine or injectable therapy?*
    • Do you have allergies to medications, food, or any vaccine (for example: eggs, gelatin, neomycin, Thimerosal, latex, etc.)?*
    • During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

    • Flu-Specific Questions

      Please answer the following questions
    • On the day of my vaccine appointment, I am age...*
    • Do you have an egg allergy?*
    • Choose your preference:*

    • RSV-Specific Questions

      RSV is another fall/winter virus that can cause hospitalization in elderly in high risk patients. Please answer the following questions.
    • On the day of my vaccine appointment, I am age...*

    • I'm sorry - Only people aged 50 years or older (regardless of risk factors) are eligible for this vaccine

    • Have you received an RSV vaccine before (regardless of when)?*

    • I'm sorry - the RSV vaccine is given once per lifetime.  You are not eligible for this vaccine.

    • I meet criteria for receiving the RSV vaccine because...*

    • COVID-Specific Questions

      Please answer the following questions
    • On the day of my vaccine appointment, I am age...*

    • I'm sorry - COVID vaccines for people under 12 years of age require discussion with the pharmacy.  Please stop this survey and call the pharmacy to discuss.

    • If given a preference, I would prefer the following COVID vaccine:*
    • On the day of my appointment...*
    • Consent/Signature 

    • Consent for services, HIPAA Privacy Information, Medical Records, and Billing:

      I have been provided with the Vaccine Information Sheet (VIS) and /or have been provided with information regarding the vaccine I am receiving. I understand all the benefits and risks of the vaccine and have had the chance to ask questions regarding it. I voluntarily assume full responsibility for any reactions that may result. I request the vaccine be given to me and authorize and direct this health care provider to use or disclose my health information to my Primary Care Physician (PCP),my insurance plan and/or state federal registries, where required for purposes of treatment, payment or other health care operations. This only allows this provider to disclose the following medical records: only documents related to the vaccination received today. If applicable, I have reviewed the eligibility requirements (posted and provided by Tomahawk Pharmacy) and confirm I have attested to my eligibility for the RSV and/or COVID vaccine. 

      To the best of my knowledge, the insurance and billing information I have supplied to this provider is accurate. In the case of a denied claim, I understand I will be billed for the vaccine and any fees associated with administering the vaccine. For Medicare Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct. I authorize the release of all records to act on this request and I request that payment of benefits be made on my behalf.

    • Date
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    • Should be Empty: