Vashon Pharmacy Immunization Screening Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Do you have any allergies?Please list them below, skip if you have none.
4
Phone NumberIf you currently receive text notifications from the pharmacy you may skip this.
Area Code
Phone Number
5
Do you have a current address on file at Vashon Pharmacy* This field is required.If no, you will be asked to supply one.
YESNO
6
Address
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Is your prescription insurance on file with us?* This field is required.If no or you have updated insurance you will be asked to provide it.
YESNO
8
Please enter your prescription insurance information below. Note, not all plans have an RX Group or PCN...if it's on your card we need it to bill.
Patient ID #
BIN #
RX Group #
RX PCN#
9
Do you have a red/white/blue Medicare ID card? (patients over 65 and/or eligible for medicare have this)IF yes, we will ask for the ID number off that card to bill Flu and Pneumonia vaccinations, all other vaccines go through drug plans typically if covered.
YESNO
10
Medicare ID #Please provide the number off of your Red-White-Blue Medicare card if applicable.
11
Primary DoctorPlease provide the doctor you would like us to send immunization notifications to. If you do not wish us to send notifications you may leave this blank.
12
Which vaccine(s) would you like today?* This field is required.check all that apply
13
Are you sick today?* This field is required.
YESNO
14
Have you ever had a serious reaction to a vaccine?* This field is required.
YESNO
15
Do you have any long-term health conditions?* This field is required.If yes, pharmacist may discuss them with you depending on the vaccine being administered.
YESNO
16
Do you have cancer, AIDS/HIV, Leukemia or any other immune system related condition?* This field is required.
YESNO
17
Do you take Prednisone, Cortisone, Steroids, Anticancer medication or have you had radiation treatment?* This field is required.
YESNO
18
Have you had a seizure, brain or other nervous system problem?* This field is required.
YESNO
19
During the past year have you received a blood transfusion of blood or blood products or been given a immune globulin or an antiviral drug?* This field is required.
YESNO
20
Have you received any vaccinations in the last 4 weeks?* This field is required.If yes, Pharmacist may discuss them with you and whether it impacts your ability to receive a vaccination today.
YESNO
21
FOR WOMEN: Are you pregnant, or is there a chance you could become pregnant in the next month?
YESNO
22
Vashon Pharmacy is receiving High Dose Flu vaccine in batched shipments from the distributor. We have a large que of patients wanting high dose flu vaccine and are alerting patients based on order of form submission. We now anticipate the next batch coming in no later than October 15. Continue to complete this form and select - Will wait for a call from the pharmacy - on the next question. Thank you for your understanding and we look forward to serving you soon.We will accept this form as a complete submission and simply ask you to verify all information is current prior to administering vaccine should this submission be more than 3 days before vaccine administration.
23
When do you plan on getting this vaccine(s)?Please note that patients who fill out their forms more than 3 days ahead of time may be asked to verify that information is still current and accurate to ensure safety.
ASAP - Im present in the store or arriving in
Later Today (>1 HR from now)
I will come in tomorrow or within 3 Days from now
I will wait for a phone call as the pharmacy staff works through the que of patients waiting for High Dose. I understand it could be 2-3 weeks before I hear back but by completing this form and assured to receive a dose.
24
Signature - please sign at bottom of acknowledgment (some formats will require you to scroll down. If using a computer use mouse to draw signature.)* This field is required.I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine. I acknowledge that my vaccination record may be shared with federal or state or city agencies for registry reporting. I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area, for 20 minutes, after the administration of the immunization. I acknowledge receipt of Vashon Pharmacy’s Notice of Privacy Practices for Protected Health Information. I acknowledge that the administration of an immunization or vaccine does not substitute for an annual check-up with the patient’s primary care physician. I have read, or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s). I fully release and discharge Vashon Pharmacy, its affiliates, officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.
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