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Immunization Screening Form - Use this form for Flu and all other vaccinations EXCEPT COVID ----  THE COVID REGISTRATION FORM IS AVAILABLE ON OUR WEBSITE @ VASHONPHARMACY.COM
Immunization Screening Form - Use this form for Flu and all other vaccinations EXCEPT COVID ----  THE COVID REGISTRATION FORM IS AVAILABLE ON OUR WEBSITE @ VASHONPHARMACY.COM
Hi there, please fill out and submit this form.
27Questions
Vashon Pharmacy Immunization Screening Form
Language
  • English (US)
  • Spanish (Latin America)
  • 1
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  • 2
    -
    Pick a Date
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  • 3
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  • 4
    Please list them below, skip if you have none.
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  • 5
    If you currently receive text notifications from the pharmacy you may skip this.
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  • 6
    If no, you will be asked to supply one.
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  • 7
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
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    • Iowa
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    • Michigan
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    • Montana
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    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Puerto Rico
    • Rhode Island
    • South Carolina
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    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    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
    • Curaçao
    • 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
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  • 8
    Required by state for registry upload
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  • 9
    Required by state for registry upload
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  • 10
    If no or you have updated insurance you will be asked to provide it.
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  • 11
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  • 12
    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.
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  • 13
    Please provide the number off of your Red-White-Blue Medicare card if applicable.
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  • 14
    Please 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.
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  • 15
    Please select from the list of available vaccines below. Please note costs associated are WITHOUT INSURANCE. Vashon Pharmacy will attempt to bill insurance and you will have a chance to review costs with pharmacy staff prior to vaccination.
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    ORDER SUMMARY
    Total costUSD
    • FluAd - High Dose Flu Vaccine
      FluAd - High Dose Flu VaccineFor those over the age of 65.
      $75.00+RemoveEdit
      Back

      1
      • 1
      • 2
      • 3
      • 4
      • 5
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      • 10
      Subtotal: $0.00
    • Flu Vaccine - (Age 3-64)
      Flu Vaccine - (Age 3-64)For all populations under 65 years old
      $35.00+RemoveEdit
      Back
    • Hep A (HAVRIX) -
      Hep A (HAVRIX) - Hepatitis A Vaccine
      $87.55+RemoveEdit
      Back
    • Hep B (ENGERIX-B)
      Hep B (ENGERIX-B) Hepatitis B Vaccine
      $78.02+RemoveEdit
      Back
    • Shingrix
      ShingrixShingles Vaccine for those over 50 years old
      $193.15+RemoveEdit
      Back
    • TDaP -Boostrix
      TDaP -BoostrixTetanus, Diptheria and Pertussis (whooping cough) vaccine
      $64.28+RemoveEdit
      Back
    • Gardasil-9 (HPV)
      Gardasil-9 (HPV)HPV Vaccine
      $279.35+RemoveEdit
      Back
    • Bexsero (Men B)
      Bexsero (Men B)Meningococcal Group B Vaccine
      $192.61+RemoveEdit
      Back
    • Polio (IPOL)
      Polio (IPOL)Polio Vaccine
      $64.49+RemoveEdit
      Back
    • Menveo (Men ACW 135)
      Menveo (Men ACW 135)Meningococcal ACW Strains Vaccine
      $167.45+RemoveEdit
      Back
    • MMR II
      MMR II MMR Vaccine - This is a live vaccine and should be given 28 days after any other vaccine.
      $114.56+RemoveEdit
      Back
    • Prevnar 20 (new Pneumonia vaccine)
      Prevnar 20 (new Pneumonia vaccine)This is the new pneumonia vaccine recommended for all patients over 65 and those with other risk factors.
      $267.30+RemoveEdit
      Back
    • Prevnar 13 (other Pneumonia Vaccine)
      Prevnar 13 (other Pneumonia Vaccine)No longer recommended for all ages, only those advised by their doctor or those who have other risk factors will receive this vaccine.
      $245.41+RemoveEdit
      Back
    • Twinrix (Hep A+Hep B)
      Twinrix (Hep A+Hep B)Combination Hep A + hep B - very useful for first dose if starting both series as they are combined
      $124.39+RemoveEdit
      Back
    • Typhim (Typhoid)
      Typhim (Typhoid)Typhoid injectable vaccine
      $141.37+RemoveEdit
      Back
    • Varivax (Varicella/Chicken Pox)
      Varivax (Varicella/Chicken Pox)Commonly referred to as the chicken pox vaccine.
      $176.73+RemoveEdit
      Back
      Total cost $0.00
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    • 16
      check all that apply, PLEASE NOTE, WE ARE NOT ACCEPTING WAITING LISTS FOR COVID-19 VACCINE AT THIS TIME.
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    • 17
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    • 18
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    • 19
      If yes, pharmacist may discuss them with you depending on the vaccine being administered.
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    • 20
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    • 21
      Press
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    • 22
      Press
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    • 23
      Press
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    • 24
      If yes, Pharmacist may discuss them with you and whether it impacts your ability to receive a vaccination today.
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    • 25
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    • 26
      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.
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    • 27
      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.
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    • 28
      If no appointment times show in the area to the right please scroll to the next month for additional appts.
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    • 29
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    • 30
      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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