Flu Vaccine 65+ 2026-27 Consent and Questionnaire

26A Picotte Drive

Albany, NY 12208

(518)435-2315

High Dose Flu Vaccine (65 y/o +) Administration Form

Please read the Vaccine Information Sheet by clicking here.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender (M/F)
Race
Ethnicity
Phone
Email
example@example.com
Home address
City
State
Zip
Insurance Plan Name
ID#
BIN
PCN
GROUP #
If you have Medicare (Red, White & Blue Card) please enter Medicare ID or last four of SSN below.
Primary Care Provider/Doctor Name
Primary Doctor's Phone Number
Format: (000) 000-0000.
Please answer the following questions. They will help us determine your eligibility to receive a vaccination today.
Do you currently feel sick?
Have you been sick in the last 2 weeks?
Do you currently have a fever?
Do you have any health conditions (e.g diabetes, heart disease, asthma, etc?)
Health Condition from above question
Have you received the flu vaccine before?
Have you had a reaction to the vaccine before?
Reaction(s) to vaccine(s), please list
Do you have allergies to medications or food?
If yes, please list:
Are you allergic to Eggs or Dairy?
Are you allergic to thimerosal?
Are you currently pregnant?
Are you a health care worker?
Have you ever had Guillain-Barre Syndrome?
Do you have a blood-clotting disorder?
Are you taking any blood-thinning medications?
If Yes, Please List
Please read carefully and sign below.

I, the undersigned, have read or had explained to me the vaccine information sheet (VIS). I understand that it is not possible to predict all side effects or complications associated with receiving vaccination I understand the risks and benefits associated with the vaccine and have had any questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the aforementioned person for whom I am authorized to make this request. I understand that my vaccination will be submitted NYSIIS (New York State Immunization Information System) unless otherwise stated.
I acknowledge that a pharmacist or certified pharmacy intern under a pharmacists supervision will be administering the vaccine.
Appointment
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Would you be interested in receiving a complimentary Narcan kit?
TYPING IN MY NAME ACTS AS A DIGITAL SIGNATURE FOR CERTIFYING THAT I REVIEWED THE VIS LITERATURE.
To be completed by healthcare provider only:
Manufacturer
Lot #
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Route
Site
Administered By
Date Given
Should be Empty: