Vaccination Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Do you weigh under 130lbs?
*
Yes
No
Females: Do you weigh over 200lbs?
Yes
No
Males: Do you weigh over 260lbs?
Yes
No
Which vaccines would you like to receive today?
*
Senior Flu
Flu
Covid
RSV
Pneumonia
Shingles
Tetanus / Whooping Cough
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Wellness Questions
The following questions will help us determine which vaccines can be given today. If a question is not clear, please ask your pharmacist.
Are you sick today?
*
Yes
No
Don't know
Have you ever had a serious reaction after receiving a vaccine?
*
Yes
No
Don't know
Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting (doctor’s office / hospital)?
*
Yes
No
Don't know
Do you have allergies to medications, food, yeast, vaccine component, or latex? Have you had a past reaction to gelatin or triple antibiotic ointment?
*
Yes
No
Don't know
If you answered, "yes" - please list.
Do you have a long term health problem such as heart disease, lung disease, asthma, liver disease, kidney disease, diabetes, alcoholism, cochlear implant, CSF leak, anemia or other blood disorder?
*
Yes
No
Don't know
If you answered, "yes" - please list.
Do you have a history of myocarditis or pericarditis, or Multisystem Inflammatory Syndrome (MIS-C/MIS-A)?
*
Yes
No
Don't know
Do you smoke?
*
Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
*
Yes
No
Don't know
In the past 6 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?
*
Yes
No
Don't know
Have you had a seizure, or a brain, or other nervous system problem, or Guillian-Barre syndrome?
*
Yes
No
Don't know
During the past year, have you received immune (gamma) globulin, blood/blood products, or an antiviral drug?
*
Yes
No
Don't know
Have you received any vaccinations in the past 4 weeks?
*
Yes
No
Don't know
Have you ever felt dizzy or faint before, during, or after a shot?
*
Yes
No
Don't know
For tetanus shots, do you have a cut injury, puncture or open wound that prompted you to get a tetanus shot?
*
Yes
No
Don't know
Are you pregnant?
*
Yes
No
Don't know
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Vaccination History
Have you received the following vaccines:
Covid
*
Yes
No
Don't know
Pneumonia
*
Yes
No
Don't know
Shingles
*
Yes
No
Don't know
Whooping Cough (Tdap)
*
Yes
No
Don't know
RSV
*
Yes
No
Don't know
Authorization and Release of Liability: I authorize the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid, or other third party payer as needed and request payment of authorized benefits to be made on my behalf to Central Drug Store, Inc. (CDSI).I acknowledge that CDSI is required to share my vaccination record with Oregon’s Alert Immunization Information System (Alert IIS).I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area for 15 minutes after the administration of the immunization.I acknowledge that the administration of a vaccine does not substitute for an annual check-up or child or adolescent well-care visit with a primary care provider.I have been provided and read, or have had read to me, the Vaccination Information Sheet (VIS) regarding the vaccine(s).I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s).I request and consent for administration of the vaccination(s) either to me or to the person named above, a minor whom I represent or person whom I am a legal guardian of, that I am authorized to sign this consent and release. I, for myself (and for the recipient of the vaccination), my heirs, executors, and assigns hereby fully release and discharge CDSI, its affiliates, officers, directors, employees, agents, and representatives from any liability for illness, injury, loss, or damage which may result there from.
Submit
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