Influenza Vaccine Form

Patient's Full Name:*

First NameLast Name

Date of Birth:*

Email:*

Confirm Email*

Phone Number:*

Sex:*

MaleFemale

Address:*

Street Address Line 2

Primary Care Doctor:

Doctor City/State:

In which arm would you like your shot?*

LeftRight

Please complete the following questions:*

	Yes	No	Don't know or N/A
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Have you had a severe allergic reaction after receiving a vaccine or injectable medication?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?
For children 6-8 years old: Have you previously received at least 2 doses of the seasonal flu vaccine?

Please specify any allergies

Please check this box if you need a High Dose Vaccine

I need a Fluzone High Dose Vaccine

Signatures

I have have given my consent to recieve the Fluzone Influenza Vaccine. I understand the benifits and risks of the vaccine being administered and authorize the administration of the vaccine to me or to the person named above for whom I am authorized to make this decision.

ATTENTION: Any child under 3 years must have a prescription for each dose of a vaccine. The parent or guardian of the child must contact their medical provider who must send a prescription into the pharmacy prior to each dose.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian or Power of Attorney) *

Clear

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Signature of Acknowledgment of Notice of Privacy Practices:*

Clear

Have you ever gotten a vaccine or prescription filled at our pharmacy?*

YesNo

Do you have prescription insurance?

YesNo

Do you have Medicare?

YesNo

Please Enter Your Medicare ID (if you are over 65)

Please take or upload pictures of front & back of insurance card for billing purposes*

Browse Files

Please confirm:*

I authorize the pharmacy to bill my insurance on my behalf for the immunization

If uninsured, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan. I understand that the flu shot will cost 30$

Please agree to the following statements*

I affirm that the information entered above is correct and accurate to the best of my knowledgeI understand that the pharmacy may ask that I wait up to 30 minutes after my injection to monitor for an allergic reaction

All information is confidential and is accessed via a secure, encrypted interface.

Follow the button below to schedule your apointment to get vaccinated

Influenza Vaccination Administration Form