Contact-free Vaccination Management

Patient Screening Questionaire

Thank you for scheduling your vaccinations at your local community pharmacy. To minimize how long you’ll need to be in the pharmacy, begin by telling us about yourself and your primary care physician.

Step 1 of 3

My Information

Please complete all required* fields in this section.

First Name *

MI

Last Name *

Date of Birth *

MM / DD / YYYY

Age *

Gender *

Please enter other gender *

Race/Ethnicity

Address Line 1 *

Address Line 2

City *

State *

Zip *

Email Address *

Phone *

My Primary Care Physician

Tell us about your primary care physician. Skip this section if you are not sure.

No PCP

I don't have a Primary Care Physician

Physician's Full Name

Physician's Phone

Physician's City

Step 2 of 3

My Pharmacy and Vaccine Selection

Load your preferred pharmacy below, then make your vaccination selections.

Schedule Your Appointment with {preferredPharmacy}

Appointments are scheduled on a first-come first-serve basis, {preferredPharmacy} will do their best to accommodate your request.

Preferred Pharmacy *

Pharmacy Email

Select a date and time: *

Which vaccine(s) would you like to receive at {preferredPharmacy}?

Vaccines *

Flu Shingles Pneumococcal HPV Meningitis Other

Please enter other vaccine(s)

Either the other vaccine(s) you would like to receive.

Vaccine Information Statements

Vaccine Information Statements (VISs) are information sheets produced by the Center for Disease Control (CDC) that explain both the benefits and risks of a vaccine to vaccine recipients.

Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines.

Download Flu Vaccine Information Statement

Download Shingles Vaccine Information Statement

Download Pneumococcal Vaccine Information Statement

Download HPV Vaccine Information Statement

Download Meningitis Vaccine Information Statement

Acknowledge VIS Access: *

I have access to VISs for the selected vaccines (excludes "Other")

Step 3 of 3

Questionaire: All Vaccines *

The following questions will help us determine your eligibility to be vaccinated today.

Are you feeling sick or experiencing a moderate to high fever today? *

Yes No Don't Know

Do you have any allergies to medications, food (i.e. eggs), latex, vaccine component (e.g. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker’s yeast or yeast)? If yes, please list: *

Yes No Don't Know

Please enter your known allergies: *

Have you ever had a serious reaction to any vaccinations, including fainting and feeling dizzy? *

Yes No Don't Know

Have you ever had a health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, or a blood disorder? If yes, please list: *

Yes No Don't Know

Please enter your known health problems: *

Have you ever had a seizure disorder for which the patient is on seizure medication(s), a brain disorder, Guillain- Barré Syndrome (a condition that causes paralysis) or other nervous system problem? *

Yes No Don't Know

For Women: Are you pregnant or considering becoming pregnant in the next month? *

Yes No Don't Know

Questionaire: Live Vaccines *

(Chickenpox, Flu Nasal Spray, MMR^® II, Oral Typhoid, Shingles, Yellow Fever)

Have you received any vaccinations or skin test within the past four weeks? If yes, please list: *

Yes No Don't Know

Please enter any vaccinations or skin test within the past four weeks: *

Do you have cancer, leukemia, HIV/AIDS, or any other condition that weakens the immune system? *

Yes No Don't Know

During the past year, have you received any transfusion of blood or blood products, or been given a medication called immune (gamma) globulin? *

Yes No Don't Know

Do you take cortisone, prednisone, other steroids, anticancer drugs, or have you had any radiation treatments? *

Yes No Don't Know

Questionaire: Flu Nasal Spray *

(Flumist^®, Quadrivalent)

Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only) *

Yes No Don't Know

Do you have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose? (For FluMist® only) *

Yes No Don't Know

Have you had the following vaccines? *

Check all that apply.

Pneumococcal Vaccine *

Yes No Don't Know

Shingles Vaccine *

Yes No Don't Know

Tdap (Whooping Cough) Vaccine *

Yes No Don't Know

Signature *

Digitally sign by entering your full name below.

Full Name *

(First MI Last)

Today's Date *

Date Signed

By signing above, I certify that I am: (a) the patient and at least 18 years of age or (b) the parent or legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of {preferredPharmacy}, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that I understand the purposes/benefits of my state’s immunization registry (“State Registry”) and the Provider may disclose my immunization information to the State Registry. I acknowledge that, depending upon my state’s law, I may prevent the disclosure of my immunization information by the applicable Provider to the State Registry by using the opt-out form. The Provider will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically consent, and to the extent required by my state’s law, by signing below, I hereby do consent to the Provider reporting my immunization information to the State Registry. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my immunization information as required or permitted by law. I voluntarily authorize and direct my healthcare provider at {preferredPharmacy} to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated at {preferredPharmacy}, my Primary Care Physician, my insurance and/or state or federal registries, where required, for the purpose of treatment, payment or other healthcare operations. I further agree to be fully financially responsible for any cost sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service.

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