Flu Vaccine Administration Record

Curbside flu shots are available from 10am to 3pm Monday through Friday. Flu shots in the pharmacy (walk-ins) are welcome any day during regular business hours. If utilizing curbside, please park in one of our designated spots and call the store at 509-713-7444 option 0 to let someone know you are here.

We are currently out of stock for the season of the Fluad (>65 y/o)

Rx Pharmacy 800 Swift Blvd Ste 140 Richland, WA 99352-3559

Phone: (509) 713-7444 Fax: (509) 713-7422

Please select what day you will be coming to the pharmacy for your flu vaccine.

Date

Name*

*

MaleFemale

Date of Birth*

Date

Address*

City*

State*

Zip*

Phone*

Race

Allergies*

Primary Care Physician

Office Phone Number

1. Do you have a fever (>100.4F), cough, or shortness of breath?*

YesNo

2. If you don't currenlty have these symptoms, have you experienced any of these symptoms in the last 14 days?*

YesNo

3. Have you been in contact with anyone who has tested positive for COVID-19 in the last 14 days?*

YesNO

1. Are you sick today?*

YesNo

2. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?*

YesNo

3. Have you ever had a serious reaction after receiving a vaccination?*

YesNo

4. 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?*

YesNo

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*

YesNo

6. In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*

YesNo

7. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?*

YesNo

8. 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)?*

YesNo

9. For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNo

10. Have you received any vaccinations in the past 4 weeks?*

YesNo

Vaccine Requested*

Secondary Vaccine Requested

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 the 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 Rx Pharmacy, 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 the vaccine(sI certify that I am at least 18 years old and hereby give my consent to the pharmacists of Rx Pharmacy to administer the vaccine(sIf 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 the pharmacist.

Signature

Clear

Date*

Date

Vaccine Administration Record

COVID Screening

Screening Questions

Consent