FSU Clinic

Framingham State University Clinic

Clinic Location:
100 State St, Framingham, MA 01702

Clinic Date & Time:

First Clinic: Wednesday 10/15 - 9:00am – 1:00pm
Second Clinic: Thursday 10/16 - 1:00pm – 4:00pm

Which clinic do you wish to attend:*

Select the vaccine recipient's age:*

3-5 yrs6-11 yrs12+ years65 or older

Date of Birth*

Date

Which vaccine(s) would you like to receive? You can have multiple vaccinations in 1 visit.*

COVID-19 (12 yrs+)Flu (Influenza) (3 yrs+)

Unfortunately we currently only offer COVID-19 vaccines to those 12 years of age and older. Please deselect COVID-19 above to continue or you will NOT be able to submit this form.

Which COVID-19 Vaccine would you like to receive?

PfizerModerna

Appointment

Name*

First NameLast Name

Calculated Age

Gender*

FMNon-binaryPrefer not to say

Cell Phone*

Home Address*

Address

Street Address Line 2

CityState / Province

Zip

Email Address*

example@example.com

Allergies*

Please answer the following:*

	Yes	No	Don't Know
Do you feel sick today?
Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
Have you ever had a reaction after receiving a vaccination, including feeling dizzy or fainting?
Do you have any health conditions such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?
Have you had a seizure, Guillain-Barre syndrome, or a brain/other nervous system problem?

For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNoI don't know

For Tdap: Do you have a cut, injury, puncture wound, or open wound that prompted you to get a tetanus shot?

YesNoI don't know

Have you tested positive for COVID-19 in the last 3 months?

YesNoI don't know

If you answered yes to the question above, did you receive antibody therapy for COVID-19 monoclonal antibodies or convalescent plasma?

YesNoI don't know

Do you have a weakened immune system due to a health condition or immunosuppressive therapy?

YesNoI don't know

You have selected COVID-19 as an option above. Please specify if you have any underlying health condition(s) that puts you at a high risk for severe outcome from COVID-19

Please certify the following:

By checking this box I certify that it has been at least 2 months since my last COVID-19 related vaccination.

Live Vaccines (MMR) Please answer the following:

	Yes	No	Don't Know
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, or Crohn's disease?
In the past 3 months, have you taken medications that weaken your immune system such as steroids (Cortisone, Prednisone) or, Immunosuppressants (Methotrexate, Humira, Cyclosporine, etc.) or, anticancer drugs, or have you had radiation treatments?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamme) globulin or antiviral drug (including acyclovir, famciclovir, valacyclovir)?
Have you received any vaccinations or skin tests in the past 4 weeks?

Have you ever had pneumonia vaccine before?

YesNoI don't know

If Yes, which pneumonia vaccine did you receive?

Prevnar 20Pneumovax 23Prevnar 13

Years since last pneumonia vaccine:

Have you ever had the shingles vaccine before?

YesNoI don't know

If Yes, which dose did you receive?

First DoseSecond Dose

Years since last shingles dose:

I have no insurance

Prescription Insurance Card

BIN #

PCN #

ID #

Rx Group #

Medical Insurance Card

Insurance Carrier

ID#

Group #

Help Desk Phone #

Note: If you have a Medicare Part A and B card (commonly issued to those 65 or older), please provide Medicare Part B Number or the last 4 digits of your SSN.

Medicare Number (from red & blue card)

OR Last 4 of your SSN

This field is optional and recommended for those who do not know their Medicare Part B number.

Primary Care Provider's Name

Primary Care Provider Phone

Primary Care Provider Address

Address

Street Address Line 2

CityState

Zip

I attest that my answers and information provided are true and accurate to the best of my knowledge. I have read, or have had read to me, the written information regarding the vaccine(s) being administered. 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 lnformation Sheet. l, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless MetroWest Pharmacy, 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). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of MetroWest Pharmacy to administer the vaccine(s). lf under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Name (Print)*

Date*

Date

Patient Signature (Parent/Legal Guardian if minor)*

Please

Vaccine Administration Record

Insurance Information

Primary Healthcare Provider Information

Consent