Medicap Pharmacy Flu and Other Vaccine Form

Name *

First Name Last Name

Birth Date *

Month Day Year

Gender *

Male Female Other

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Email

example@example.com

Plese Select a Date and Time to schedule your vaccine below. *

Questionnaire for Immunization *

	Yes	No	Don't Know
Do you feel sick today?
Do you have an allergy to Eggs or Latex?
Have you ever had a reaction or fainted after receiving any vaccination?
Are you pregnant or planning on becoming pregnant?
Hae you ever had a seizure disorder, brain disorder, or Guillain-Barre Syndrome?

Please List Severe Allergies if any

Vaccine(s) I wish to receive today *

Influenza Quad Shingles (Shingrix) Tdap (Boostrix) Prevnar 13 (Pneumonia 1) Pneumovax 23 (Pneumonia 2)

By signing below,

I understand the benefits and risks of the vaccine as described in the Vaccine Information Statement (VIS) that is available by clicking on the image above representing the vaccine I wish to recieve.

I have received a copy of the notice of privacy practices Click here for 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.

Please sign below and click submit to complete your form. *

Clear

Vaccine / Lot / Date / Exp Admin Site

R / L Arm

Signature of Pharmacist/Technician who administered vaccine.

______________________________________________ Date ___/___/______

Click on the image below of the vaccine(s) you wish to receive to view the vaccine information sheet.