• CP: SUNY Plattsburgh Flu Clinic 09-29-26 Immunization Screening and Consent Form

  • Are you a student, staff member, or employee of SUNY Plattsburgh?*
  • SUNY Plattsburgh Flu Clinic

  • Patient Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Format: (000) 000-0000.

  • Immunization Screening Questions

  • Are you feeling sick today?*
  • Have you ever felt faint or fainted after receiving an immunization?*
  • Do you have any allergies to medications, foods, or vaccines?*
  • Have you ever had a serious allergic reaction to a vaccine or vaccine ingredient?*
  • Have you ever had Guillain-Barré syndrome?*
  • Do you have a history of immune system problems, cancer, leukemia, HIV/AIDS, or any other condition that affects your immune system?*
  • Are you pregnant or could you become pregnant in the next month?*
  • Are you breastfeeding?*
  • Are you currently taking any medications that affect your immune system, such as steroids, chemotherapy, or drugs after an organ transplant?*
  • Have you received any vaccines in the past 4 weeks?*
  • Have you had a transfusion of blood or blood products, or been given immune globulin or antiviral medicine in the past year?*
  • Do you have any chronic medical conditions or other health concerns that should be known before immunization?*
  • Do you have a moderate or severe illness with or without a fever?*
  • Have you ever had a serious reaction after receiving an immunization?*
  • Is the person receiving the vaccine today under the age of 18?*

  • Immunization Agreement

  • Click here for the current Influenza VIS

  • I have read and understand the Vaccine Information Statement (VIS) for the vaccine(s) I am receiving.*
  • I have had the opportunity to ask questions and have had them answered to my satisfaction.*
  • I consent to receive the vaccine(s) recommended by the healthcare provider.*
  • I understand that I may experience side effects and know when to seek medical attention if needed.*
  • I will notify Condo Pharmacy of any adverse events associated with immunization.*
  • Permission is hereby granted to the Condo Pharmacy to release information to my primary care provider, identified above, regarding any vaccinations received today.*
  • Hold Harmless*

  • Patient Authorization

  • Format: (000) 000-0000.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Insurance Information - If not on file

  • BIN, PCN, ID, and RxGroup are needed for prescriptions.  If you have NYRx benefits, only the CIN is needed and it may be placed in the ID field. Medical insurance may differ and be needed for services such as immunization and testing.

    You may call the pharmacy with this information or provide a copy of any cards at your appointment.

  • NYSIIS Reporting

  • Condo Pharmacy and the New York State Department of Health want to inform you about the Statewide Immunization Information System (IIS). By law, immunizations given to patients under the age of 19 must be reported into a secure web-based IIS and this electronic system is called the New York State Immunization Information System (NYSIIS). For patients aged 19 and older, immunizations may be reported to NYSIIS with patient consent. Inclusion of adults will significantly contribute to a fully-developed, population-based database of accurate immunization records, and complete data is essential to developing statewide immunization programs intended to reduce the burden of vaccine preventable disease.
  • Patient Consent to Report to NYSIIS*
  • Patient Race
  • Should be Empty: