Name
*
First Name
Last Name
Business or School Name
*
Mailing Address
*
City, State, Zip
*
County
*
Age
*
Email Address
*
Telephone Number
*
Date of birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Emergency Contact Name
*
First Name
Last Name
Emergency contact Relation
Emergency contact phone#
*
Primary Physician
*
Primary Physician City
*
Primary Physician State
*
Are you sick today?
*
Yes
No
Do you have allergies to medications, food, a vaccine component, or latex?
*
Yes
No
Have you ever had a serious reaction after receiving a vaccination?
*
Yes
No
Do you have cancer, leukemia, AIDS, rheumatoid arthritis or other immune system problems?
*
Yes
No
In the past 3 months, have you taken medicine that affects your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease or psoriasis; or have you had radiation treatments?
*
Yes
No
Have you ever had a seizure or other nervous system problem?
*
Yes
No
Have you received ANY vaccinations in the past 4 weeks?
*
Yes
No
During the past year, have you received a blood transfusion, blood products, or been given immune (gamma) globulin or an antiviral drug?
*
Yes
No
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes),anemia, or other blood disorder?
*
Yes
No
For women: are you pregnant or do you plan to become pregnant in the next three months?
*
Yes
No
Have you been exposed to COVID-19 in the last 14 days?
*
Yes
No
Are you allergic to eggs?
*
Yes
No
Are you interested in shingles or pneumonia vaccinations?
*
Yes
No
Are you interested in COVID-19 rapid testing?
*
Yes
No
Vaccine Information statement
I have read, or had explained to me, the vaccine information statement dated 08/15/19 for INACTIVATED INFLUENZA vaccine. I understand the risks and benefits. I have been provided an opportunity to ask questions and they were answered to my satisfaction. I hereby give my consent to receive the vaccine listed in the VIS and to communicate the administration to the vaccine to my primary care pracitioner. I have read the posted copy of the Patient's Privacy Policy (a copy is available upon request). Sign here:
*
Clear
Date
*
/
Month
/
Day
Year
Date
Front of Insurance card
Back of insurance card
Insurance Cardholder Name (If no photo provided)
Rx BIN
Rx Grp
Rx PCN
Cardholder ID
Notes
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