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

Flu/COVID/RSV Vaccine Administration Record and Screening

Information collected on this form will be used todocument authorization for receipt of vaccines. The information will be shared through the Wisconsin ImmunizationRegistry (WIR) with other health care providers directly involved with thepatient to assure completion of the vaccine schedule. Information collected on this form isvoluntary and confidential.

Patient Information
Full Name*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
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.
Age in years (calculated from date of birth)
Phone*
Email (optional)
example@example.com
Address*

Address

Street Address Line 2

CityState

Zip
Medicare Number (if applicable)
Do you have a Medicare Advantage plan?*

YesNo
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?*

Flu (influenza) for ages 12+RSV (respiratory syncytial virus) for age 50+COVID (Sars-Cov-2)

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.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Flu/COVID/RSV Vaccine Administration Record and Screening

Flu-Specific Questions

RSV-Specific Questions

COVID-Specific Questions