Norland Immunization Questionnaire & Consent Form

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Please choose:
Appointment
Appointment Date and Time:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Immunization Questionnaire & Consent Form
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Gender:
Phone:
Format: (000) 000-0000.
Email Address:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Emergency Phone:
Format: (000) 000-0000.
Primary Doctor:
Drug Allergies:
If you do not have insurance, please type NA in the next 6 boxes.
Name EXACTLY as shown on Medicare or Insurance card:
Medicare or Insurance ID #:
RxGroup:
RxBIN:
RxPCN:
The following questions will help us determine which vaccine(s) may be given today. If a questions is not clear, please ask your Norland Avenue pharmacist to explain it.

Rows	Yes	No	Unsure
Are you sick today or do you have a fever?
Do you have allergies to eggs, latex, or any vaccine component (neomycin, formaldehyde, gentamicin, thimero- sal, bovine protein, phenol, polymixin, gelatin, baker's yeast, or yeast)?
Have you ever had a serious reaction after receiving a vaccination?
Have you received any vaccinations in the past four weeks?
Do you have a neurological disorder such as seizures or other disorders that affect the brain or have had a dis- order that resulted from a vaccine (i.e. Guillain-Barre Syndrome)?
For women: Are you pregnant, becoming pregnant in the next three months, or are you nursing?
For patients over 50 OR those with a chronic condition such as asthma, COPD, or diabetes OR those that
smoke: Have you received the Pneumococcal or "pneumonia" vaccine?
Are you up-to-date on your tetanus and pneumonia vaccinations?
Have you had any form of prednisone (orally or cortisone injection) in the last two to four weeks? (If you answer yes to this question, you may need to wait 2 weeks before getting your vaccination. Call the pharmacy with questions.)

I authorize the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medi- caid, or other third party payer as needed and request payment of authorized benefits to be made on my behalf to Norland Avenue Pharmacy.
I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine.
I acknowledge that my vaccination record may be shared with federal or state agencies for registry reporting.
I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area, after the administration of the immunization, for 20 minutes.
I have 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 fully release and discharge Norland Avenue Pharmacy, affiliates, and their employees from any liability for illness, injury, loss, or damage which may result there from.
Patient Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Pharmacy Use Only

Immunization Questionnaire & Consent Form