Holliston Health Department Cinic

Vaccine Administration Record

Administration Records: Informed Consent for Vaccination
Holliston Health Department Cinic

Clinic Location:
Holliston health department,
at the Placentino Cafeterium in Holliston
235 Woodland St, Holliston, MA 01746

Clinic Date & Time: 10/18/25, Saturday, 9:00am - 12:00pm

Vaccines Offered: Flu (High-Dose and Regular) and updated COVID-19 vaccines
Which clinic do you wish to attend?*
Select the vaccine recipient's age:*

3-5 yrs6-11 yrs12+ years65 or older
Date of Birth*

MonthDayYear
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+)
You have selected COVID-19 from the options above. Please select which product you would like to receive.

PfizerModerna
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.
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
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:
Insurance Information

**Please fill out your insurance information completely in order to check coverage for the vaccines requested
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 Healthcare Provider Information

Vaccination information from this visit will be sent to the provider listed below:
Primary Care Provider's Name
Primary Care Provider Phone
Primary Care Provider Address

Address

Street Address Line 2

CityState

Zip
Consent
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*

MonthDayYear
Date
Patient Signature (Parent/Legal Guardian if minor)*

Clear
Please
Should be Empty:

Vaccine Administration Record

Insurance Information

Primary Healthcare Provider Information

Consent