LTC Scripts Adult Immunization Consent, Screening & Vaccine Administration Record
Complete the intake, screening, vaccine selection, consent, and administration record with required signatures and documentation.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility Name
Facility Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility contact
Facility phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Facility email
example@example.com
Insurance information
Alternatively, you can upload the patients insurance cards at the bottom of the section
Medicare ID
Medicare advantage plan
Secondary insurance
Member ID
BIN number
PCN
GROUP #
Please upload patient Face Sheets & insurance cards here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
General Medical Screening
Have you received any vaccines in the last four weeks?
*
Yes
No
Is the patient currently sick today?
*
Yes
No
Does the patient have a fever now or within the last 24 hours?
*
Yes
No
Does the patient have any allergies?
Food
Medication
Latex
Vaccine component
Other
Please describe the allergy and any reaction experienced
Has the patient ever had a bad reaction to a vaccine?
*
Yes
No
Please describe the prior vaccine reaction
Does the patient have a bleeding disorder or easy bruising?
*
Yes
No
Is the patient taking blood thinners or other anticoagulant medicines?
*
Yes
No
Is the patient immunocompromised or taking medicines that weaken the immune system?
*
Yes
No
Is there any possibility the patient is pregnant or breastfeeding?
*
Yes
No
Not applicable
Vaccine-Specific Screening
Selected vaccines
*
Influenza
COVID-19
RSV
Shingles
Pneumovax 23
Prevnar
Tetanus
Hepatitis A
Hepatitis B
Tdap
Td
MMR
Varicella
Other
Influenza screening
Have you ever developed Guillain-Barré Syndrome within 6 weeks of receiving an influenza vaccine?
Yes
No
Have you already received this season's influenza vaccine?
Yes
No
COVID-19 screening
History of myocarditis or pericarditis?
Yes
No
Previous severe reaction to a COVID-19 vaccine?
Yes
No
RSV screening
Shingrix (Shingles) screening
Have you previously received Shingrix?
Yes
No
If Yes, Dose1 or Dose 2
Dose 1
Dose 2
Approximate date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pneumococcal screening
Have you previously received a pneumococcal vaccine?
Prevnar
Pneumovax
Don't Know
Approximate year
Tetanus screening
Approximately when was your last tetanus containing vaccine?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MMR screening
Have you previously received the MMR vaccine?
Yes
No
Varicella screening
Have you previously had chickenpox or received the Varicella vaccine?
Yes
No
CONSENT SECTION (MUST COMPLETE)
Who is completing this consent?
*
Patient
Healthcare proxy
Medical power of attorney
Court appointed guardian
Parent(if applicable)
Other
Electronic signature
*
Healthcare Professional Administration Record
Vaccine Administered
Manufacturer
Lot Number
Expiration date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Administration Date and Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Dose
Route
Please Select
Intramuscular (IM)
Subcutaneous (SC)
Intranasal
Oral
Other
Injection Site
Please Select
Left Deltoid
Right Deltoid
Left Thigh
Right Thigh
Left Arm
Right Arm
Other
Vaccine Information Statement (VIS) Edition Date
Administrator Name
First Name
Last Name
Credentials
NPI
Vaccine administrator Signature
Final Certification and Clinical Notes
Submit
Submit
Should be Empty: