Vaccine Administration Record
Name
*
First Name
Last Name
Gender at Birth
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Format: (000) 000-0000.
Social Security #
*
Medicare # (including letters)
Allergies
*
Primary Care Physician & Phone Number
Ethnicity (optional)
Caucasian
African American
Hispanic
Asian
American Indian
Other
Screening Questions
Screening Questions
*
Rows
YES
NO
1. Are you sick today?
2. Do you have any allergies to medications, foods (e.g. eggs), latex, or a vaccine component (e.g. gelatin, neomycin, polymyxin, yeast, thimerosal, etc.)? If yes, please list below.
3. Have you ever had a serious reaction (including fainting) after receiving a vaccination? (if fainting, need vagal precautions built into protocol with triage and treatment recommendations should this occur at pharmacy).
4. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease(e.g., diabetes) anemia or other blood disorder? (If so, these need to be addressed in protocol based on current accepted guidelines).
5. Do you have cancer, leukemia, HIV/AIDS, or any other Immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease?
6. In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids or anticancer drugs, or have you had radiation treatments?
7. Have you had a seizure, or a brain or other nervous system problem, or Guillain-Barre?
8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?(Response needs to be addressed in protocol).
9. For women, are you pregnant or is there a chance you could become pregnant during the next month? (Protocol needs to address for specific vaccines.)
10. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a physician's office or hospital? (If answer is yes, this is a hard stop).
11. Have you received any vaccinations in the past 4 weeks? (Question not required for inactivated injectable Influenzas but is for all other Immunizations Including live attenuate Internasal Influenza.)
12. For Tdap and adult Td (ONLY). Do you have an open wound, puncture or tissue tear that prompted you to get a tetanus shot? (If answer is yes, this is a hard stop).
If yes, please list (Allergies details)
I have read, or have had read to me, the written information regarding the vaccine(s) marked below. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet for each vaccine I am receiving today. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify and hold harmless Mutual Drug, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s) marked below. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of the Mutual Member Drug Store to administer the vaccine(s) marked below. If under 18 years old signature by parent or guardian required. I AGREE TO WAIT NEAR THE VACCINATION LOCATION FOR APPROXIMATELY 15 MINUTES FOR OBSERVATION BY A MUTUAL DRUG MEMBER PHARMACIST.
Name (print)
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
https://www.chinookrx.com/_files/ugd/cbfd95_749bf1b110dd44ada780417cf66fe727.pdf
Name (print)
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vaccine to be administered
Influenza
Pneumococcal Polysaccharide
Pneumococcal Conjugate
Shingles
Hepatitis A
Hepatitis B
Meningococcal Polysaccharide
Meningococcal Conjugate
Meningococcal B
Tetanus diphtheria
Human Papillomavirus
Tetanus and Diphtheria Toxoids and Pertussis
Tetanus Toxoid
COVID
1. Vaccine Administration Details
Vaccine Name and Manufacturer
Please Select
Fluad 45mcg PFS - Seqirus
Fluzone 45mcg PFS - Sanofi
Fluzone 45mcg Vial - Sanofi
Mnexspike - Moderna
Lot # & Exp Date
Please Select
6UA8U1G, 5/13/27
3062185, 4/12/27
6UA57U2, 6/30/27
Lot # & Exp Date
Please Select
6UA8U1G, 5/13/27
3062185, 4/12/27
Admin & VIS Given Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Offsite Administration?
Y
N
Location
Site of Injection
LD
RD
Date of VIS
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of administrator of vaccine
2. Vaccine Administration Details
Vaccine Name and Manufacturer
Please Select
Fluad 45mcg PFS - Seqirus
Fluzone 45mcg PFS - Sanofi
Fluzone 45mcg Vial - Sanofi
Mnexspike - Moderna
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Site of Injection
LD
RD
Date of VIS
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of administrator of vaccine
PHARMACIST NOTES
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