Felicity Pharmacy Vaccine Screening Form

Patient Screening Form/ Vaccination Receipt
Date of Vaccination *

Month Day Year
MM/DD/YYYY
Patient Name: *
First and Last Name
DOB: *
MM/DD/YYYY
Address *

Street Address

APT #

City State

Zip Code
Cell Phone #:
Email
example@example.com
Please answer the following questions
Are you sick today? *

Yes No
Do you have allergies to medications, food, a vaccine component or latex? *

Yes No
If, Yes Please Describe
Have you ever had a severe reaction after receiving a vaccination? *

Yes No
If, Yes Please Describe
Have you ever had seizure or brain or other nervous system problem? *

Yes No
If, Yes Please Describe
Have you ever had Guillain-Barre syndrome within the last 6 weeks? *

Yes No
Which arm would you like to get the injection on? *
Immunizer Name
Signature Of Immunizer

Clear
Vaccine
Exp. Date

Month Day Year
Date
Lot #
Manufacturer
Site of Injection
Make sure to copy over the patient preferred arm
VIS Edition Date

Month Day Year
MM/DD/YYYY
Date VIS Given

Month Day Year
MM/DD/YYYY
Date:

Month Day Year
MM/DD/YYYY
Does the patient authorize this pharmacy to report the administration of this immunization(s) to the Citywide Immunization registry (CIR)?

Yes No
Does the patient authorize this pharmacy to report the administration of this immunization(s) to their Primary Health Care Provider?

Yes No
Patient Signature *

Please Sign Above Clear
Should be Empty:

Patient Screening Form/ Vaccination Receipt