Wilson Team vaccine clinic November 14th

Vaccine Administration Record Form

All The Vaccine Provided by The Medicine Shoppe of Shillington
Vaccine Clinic -Wilson School District.

Location: Wilson High School Lower House Cafeteria.

Date: November 14th 2025 Time: 3:00 pm to 5:45 pm
Are you a customer or received any vaccine from The Medicine Shoppe in the past?*
Select Your Desired Vaccine(s). You may select up to 3 vaccines.*

Other (Pneumonia, RSV, Shingrix, Tetnus, Hep B., Meningitis)
Select an appointment time:*
First Name *
Last Name *
Date of Birth*

MonthDayYear
Gender*
Vaccine Recipient Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code

Please answer "Yes" or "No" to the questions below concerning the patient's Medical History. The caregiver may fill this out on behalf of the patient. If unsure or you answer "Yes" to any of these and have concerns, please consult your doctor prior to receiving a vaccine. To save you time in person, we ask these questions now.*

Rows	Yes	No
1. Are you feeling sick today?
Are you allergic to any vaccines, medications, or foods?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have any immune system condition or take medications affecting immunity?

For Women Only: Are you pregnant?
Which arm would you like the vaccine in?*
CONSENT & WAIVER: By clicking the box below, I am indicating my consent and agree my electronic signature is the legal equivalent of my manual signature on this Agreement. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so. Please note that patients under 18 must have the consent of a parent or guardian. If I am receiving a COVID-19 vaccine dose, I attest I am eligible for that dose according to current recommendations from the CDC*
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*
Date Signed *

MonthDayYear
Date
Should be Empty:

Vaccine Administration Record Form