Vaccine Request Form
Pharmacy Location
*
Please Select
Towne and Country
Save-Rite Drugs Irvington
Save-Rite Drugs Brandenburg
Save-Rite Drugs Radcliff
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth:
*
/
Month
/
Day
Year
Date
Address
*
Address
Street Address Line 2
City
State
Zip
Phone Number
*
Please enter a valid phone number.
Allergies (to medications, latex, eggs or vaccines):
*
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Primary Care Physician:
*
Primary Care Physician Phone Number:
*
Please enter a valid phone number.
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Screening Questions
1. Are you sick today?
*
Yes
No
Please explain more.
*
2. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
*
Yes
No
Please explain more.
*
3. Have you ever had a serious reaction after receiving a vaccination?
*
Yes
No
Please explain more.
*
4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
*
Yes
No
Please explain more.
*
5. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes) anemia or other blood disorder?
Yes
No
Please explain more.
*
6. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Cron's disease, herpes, or cold sores?
*
Yes
No
Please explain more.
*
7. In the past 3 months, have you taken any medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
*
Yes
No
Please explain more.
*
8. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?
*
Yes
No
Please explain more.
*
9. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug (including acyclovir famciclovir, valacyclovir)?
*
Yes
No
Please explain more.
*
10. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
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Yes
No
Please explain more.
*
11. Have you received any vaccinations or TB skin test in the past 4 weeks?
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Yes
No
Please explain more.
*
12. Do you have a history of fainting, particularly with vaccines?
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Yes
No
Please explain more.
*
13. For Tdap and adult Td: Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?
*
Yes
No
Please explain more.
*
14. For Zoster: Have you had a past reaction to gelatin or triple antibiotic ointment?
*
Yes
No
Please explain more.
*
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Consent
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccine(s) being administered and have received a copy of a current Vaccine information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Save-Rite Drugs, Inc., its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Save-Rite Drugs, Inc. to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by pharmacist.
First and Last Name (print)
*
Signature
*
Clear
Date
*
/
Month
/
Day
Year
Date
Submit
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