CJRPC @ AMVETS, Jackson, Vaccine Clinic 2026: Intake form

CENTRAL JERSEY RIFLE AND PISTOL CLUB

VACCINE CLINIC:

AMVETS

1290 TOMS RIVER ROAD

JACKSON, NJ 08527
733 NORTH BEERS STREET, STE L-1, HOLMDEL, NJ 07733

Phone: 732-888-0303; www.BayshoreRXNJ.com
CLINIC USE ONLY
Vaccine Intake Questionnaire
Please select clinic date:
Select 1 vaccine from list below. Use 1 form for 1 vaccine only, if you are getting additional vaccine, use new form.

Pneumonia or any other vaccine
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender:
Ethnicity:

Other
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Responsible Party Name:
Address:
Phone:
Format: (000) 000-0000.
Medical Insurance Payer:
Policy or ID #
Group#
Relationship:
Take photo of your insurance card (front):
Take photo of your insurance card (back):
Upload photo of your driver's license (front)
List any known Allergies:
List any known Medical Conditions:
Primary Care Physician:
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HIPAA Privacy Information and Medical Records
1) I have acknowledged that I have received the provider's Inc Notice of Privacy Practices which may be provided at my request.
2) For Medicare, Medicaid, or Insurance Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct.
3) I authorize the release of all records to act on this request and I request that payment of benefits be made on my behalf.
Signature of patient or guardian:
Date:

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

CLINIC USE ONLY
Vaccine Consent and Administration
Have you had other vaccines in the past 4 weeks? If Yes, what was given and when (we will confirm this at the time of the appointment):

Please answer the following questions:

Rows	Yes	No	Don't Know
1. Are you sick today? (For example: a cold, fever, acute illness) (We will confirm this at the time of the appointment)
2. Do you have allergies to medications, food, or any vaccine? (For example, eggs, gelatin, neomycin, Thimerosal, latex, etc.) Please list
3. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
4. Do you have cancer, leukemia, AIDS, or any other immune system problem?
5. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
6. Have you ever had a reaction after receiving a vaccine, including feeling faint or dizzy?

Please list details:
Please read ALL of the following 3 statements, if consent is given, please and sign and date below.
1) I have been provided with the Vaccine Information Sheet (VIS) and/or been provided with information regarding to the vaccine I am receiving.
2) I understand all the benefits and risks of the vaccine and have had the chance to ask questions regarding it. I voluntarily assume full responsibility for any reactions that may result.
3) I request the vaccine be given to me and authorize and direct this health care provider to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated by this provider (standing order practitioner), my Primary Care Physician (PCP), my insurance plan and/or state federal registries, where required for purposes of treatment, payment or other health care operations. This only allows this provider to disclose the following medical records: only documents related to the vaccination received today. This authorization will remain in effect until my health care provider discloses my health information to the recipient identified above; my health care provider cannot guarantee that the recipient will not disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. I understand that I may refuse or revoke this Authorization at any time. I understand that this authorization will remain in effect until the term of this authorization expires or I provide a written notice of revocation to my health care provider. The revocation will be effective immediately upon my health care provider's receipt of my written notice.
Signature of patient or guardian:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Vaccine Intake Questionnaire

HIPAA Privacy Information and Medical Records

CLINIC USE ONLY