Section 1: Vaccine Recipient Information
Section 2: Pre Vaccination Assessment:
The following questions will help us determine if there is any reason you should not get the vaccine(s) today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain.
Prescription insurance (type "1" if pharmacy has): ID #: * RX BIN: * RX GROUP (GRP): * RX PCN: *
Section 3: Consent
I have read or have had explained to me the information provided in the Vaccine Information Statement (FLU VIS), (Shingrix VIS), (Tdap VIS), (PPSV23 VIS). I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of my reqested vaccine(s) and ask that the vaccine(s) be administered to me or the person named above for whom I am authorized to make this request.