IMMUNIZATIONS

EASY - FAST - CONVENIENT

Section 1: Vaccine Recipient Information

Name: *

Date of Birth:*

Phone Number:*

Email Address:

Primary Healthcare Provider:

Address:*

Street Address (NO PO BOXES)

Street Address Line 2

CityState

Zip Code

Gender*

Please select requested vaccine:*

Shingrix (50+, 2 shots total: 2-6 months apart)Tetanus (Adacel)Pneumonia (65+, or 18+ if has one of the following: COPD/Diabetes/Smoker)

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.

Please answer the following:*

	Yes	No	Don't know
1. Are you feeling sick today?
2. Have you ever had a serious reaction after receiving a vaccination?
3. Do you have allergies to a vaccine component, thimerosal, neomycin or latex?
5. Have you been ever diagnosed with Guillian-Barré Syndrome or a brain disorder (MDS / Huntington's disease)?
6. Are you currently taking a steroid medication, such as prednisone?
7. Do you have an immunocompromising condition or going through chemotherapy?
8. Do you have cerebrospinal fluid leak or cochlear implant?

Appointment

Prescription insurance (skip if flu shot previously from Scott Pharmacy and no change from last year):
ID #: RX BIN:
RX GROUP (GRP): RX PCN:

MEDICARE PATIENTS:
PART B NUMBER (RED/WHITE/BLUE CARD):

Section 3: Consent

I have read or have had explained to me the information provided in the Vaccine Information Statement (SHINGRIX VIS)(TETANUS VIS)(PNEUMONIA VIS). I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of my requested vaccine and ask that the vaccine be administered to me or the person named above for whom I am authorized to make this request.

Signature:*

Clear

Immunizations Consent Form