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Immunization Screening Form - DO NOT USE FOR COVID-19 VACCINE SIGNUP -FORMS THAT DESIGNATE COVID VACCINE IN THE WRITE IN AREA OF VACCINE REQUESTED WILL BE DISCARDED.
Immunization Screening Form - DO NOT USE FOR COVID-19 VACCINE SIGNUP -FORMS THAT DESIGNATE COVID VACCINE IN THE WRITE IN AREA OF VACCINE REQUESTED WILL BE DISCARDED.
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24Questions
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
    Please list them below, skip if you have none.
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  • 4
    If you currently receive text notifications from the pharmacy you may skip this.
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    Enter
  • 5
    If no, you will be asked to supply one.
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  • 6
    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
    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
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    Enter
  • 7
    If no or you have updated insurance you will be asked to provide it.
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    Enter
  • 8
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    Enter
  • 9
    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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    Enter
  • 10
    Please provide the number off of your Red-White-Blue Medicare card if applicable.
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    Enter
  • 11
    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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    Enter
  • 12
    check all that apply, PLEASE NOTE, WE ARE NOT ACCEPTING WAITING LISTS FOR COVID-19 VACCINE AT THIS TIME.
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    Enter
  • 13
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    Enter
  • 14
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  • 15
    If yes, pharmacist may discuss them with you depending on the vaccine being administered.
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    Enter
  • 16
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    Enter
  • 17
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    Enter
  • 18
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    Enter
  • 19
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    Enter
  • 20
    If yes, Pharmacist may discuss them with you and whether it impacts your ability to receive a vaccination today.
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    Enter
  • 21
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    Enter
  • 22
    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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  • 23
    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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  • 24
    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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