ACTS PHARMACY SCHEDULER

Acts Pharmacy and Healthcare Services Scheduler
What appointment are you scheduling?*

Child Immunization (6 months to 18 years old)Adult Immunization (19 years old and above)Pre-employment Vaccination/Screening ***Tacoma Pierce County Health Dept. Employees/Interns Only***Laboratory draw (please call Pharmacy to schedule appointment 253-272-0324)Compression Socks (There is a $25 fitting fee due at appointment time)FOR RX STAFF ONLY
You are eligible to get the mpox vaccine if you: 1. Had a high-risk exposure to a person diagnosed with or exposed to mpox. OR 2. Are a gay, bisexual or other man or transgender person who has sex with men. OR 3. Exchanged sex for money, drugs or other purposes in the past 6 months. OR 4. Used methamphetamine in the past 6 months. OR 5. Were sexually assaulted. OR 6. Had a new diagnoses in the last 12 months of one or more nationally reportable sexually transmitted diseases; such as acute HIV, chancroid, chlamydia, gonorrhea, or syphilis. OR 7. Are taking PrEP to prevent HIV infection. OR 8. Had multiple or anonymous sex partners in the last 6 months.*

I qualifyI do not qualify
For Lab Services please call us at (253) 272-0324 to schedule an appointment!

Please email prior vaccine records to admin@actspharmacy.com---the review process may take up to 1 week for out of state or out of country records.
Please select the reason for vaccination so that we can accurately assist you*

CollegeEmploymentElementary, Middle, High schoolsImmigrationPre-School and Child CareTravelUpdate existing vaccines

Please pick a day and time for your appointment. If you are getting a vaccine(s), you will be asked to stay close to the vaccination area for an additional 15-30 minutes for observation*

PATIENT DEMOGRAPHICS

Please complete information completely and accurately.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Patient Height and Weight*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

FemaleMaleUnknown
Race:*
Ethnicity:*
Patient Phone Number*
Email: (Please make sure this is typed correctly. You will not receive a confirmation email if this is incorrect.) *
example@example.com
Primary Care Provider (PCP) Name

First NameLast Name
List allergies: (e.g. eggs, penicillin, etc.)*
List Health Conditions: (e.g. hypertension, diabetes, hypothyroidism, etc.)*

Payment

Vaccines and administration fees may be billed to your pharmacy or medical benefits . Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
Choose a payment method*

No insurance for 19yo and up ONLY ($23 admin fee per shot may be applied for some vaccines)No insurance for 18yo and younger ONLY ($23 admin fee per shot may be applied)My insurance is already on file with Acts Pharmacy.WA Medicaid/Managed Medicaid PlanCommercial InsuranceMedicare Part B (may be billed for flu and pneumonia vaccines)Medicare Part D/ Medicare Advantage
Please take a photo of your PHARMACY BENEFIT card for billing purposes. Kindly bring your all your insurance card(s) to your appointment.
Please take a photo of your MEDICAL BENEFIT card for billing purposes. Kindly bring your all your insurance card(s) to your appointment.

Any other comments?*
Should be Empty:

	Yes	No	Don't Know or N/A
1. Are you sick today?
2. Do you have any allergies to medications, food, eggs, yeast, latex or a vaccine component?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines outside of a medical setting?
5. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?
6. Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?
7. 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?
8. Have you had a seizure, brain/other nervous system problem or Guillain Barre?
9. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug (including acyclovir, famciclovir, valacyclovir)?
10. Have you received any vaccinations or TB skin test in the past 4 weeks?
11. Do you have a history of fainting, particularly with vaccines?
12. For women: Are you pregnant or is there a chance you could come become pregnant during the next month?
13. For Tdap and adult Td: Do you have a cut, injury, puncture or open would that prompted you to get a tetanus shot?

Vaccine	Manuf	Lot#	Exp date	Sig	Admin site	VIS date
Covid-19	Moderna Novavax			Inj 0.5ml IM Inj 0.25 ml IM		10/19/23
Fluad65+/Flucelvax Afluria/ Fluarix	Seqirus Sanofi			Inj 0.5ml IM		08/06/21
Prevnar 20 Pneumovax 23	Pfizer Merck			Inj 0.5ml IM		05/12/23 10/30/19
Daptacel (DTap) Boostrix (Tdap)	Sanofi GSK			Inj 0.5ml IM		08/06/21
Engerix B 10mcg Engerix B 20mcg Heplisav	GSK GSK Dynavax			Inj 0.5ml IM Inj 1 ml IM		05/12/23
Havrix Adult / Ped	GSK			Inj 0.5ml IM Inj 1 ml IM		10/15/21
Gardasil-9 (HPV)	Merck			Inj 0.5ml IM		08/06/21
Ipol (Polio)	Sanofi			Inj 0.5ml IM		08/06/21
Menquadfi (Meningococcal)	Sanofi			Inj 0.5ml IM		08/06/21
MMR	Merck			Inj 0.5ml SC		08/06/21
Varivax / Proquad	Merck			Inj 0.5 ml SC		08/06/21
Shingrix/Arexvy	GSK			Inj 0.5ml IM		S: 02/04/22 R: 10/19/23
Kinrix/Pediarix	GSK			Inj 0.5ml IM		10/15/21
Vaxelis/Pentacel	Sanofi/Merck			Inj 0.5ml IM		10/15/21
ActHiB	Sanofi			Inj 0.5ml IM		08/06/21

Acts Pharmacy and Healthcare Services Scheduler

PATIENT DEMOGRAPHICS

Payment

SCREENING QUESTIONS

Consent to Vaccination