Vaccine Administration Form

Please add the date and time of your scheduled appointment (MM-DD-YYYY) HH:MM)*

What is the name of the clinic (school name or workplace or place of worship) you will be attending? If you don't know, the location address suffices. If it is at the pharmacy, write "Soleil".*

Legal Full Name (Last Name, First Name) - do not use nickname*

Date of Birth (MM/DD/YYYY)*

Date

Patient/Guardian Phone Number (000) 000-0000*

Please enter a valid phone number.

Gender*

Race*

Address*

Address

Street Address Line 2

CityState

Zip

Mother's Maiden Name*

Allergies (Write N/A if you don't have any allergies)*

Primary Care Physician*

Office Phone

1. Are you sick today?*

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

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

4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*

5. 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?*

6. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed withrheumatoid arthritis, ankylosing spondylitis, Crohn?s disease, herpes, or cold sores?*

7. 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?*

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

9. 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)?*

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

11. Have you received any vaccinations or TB skin test in the past 4 weeks?*

12. Do you have a history of fainting, particularly with vaccines?*

13. For Tdap and adult Td: Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?*

14. For Zoster: Have you had a past reaction to gelatin or triple antibiotic ointment?*

INSURANCE INFORMATION: Fill the appropriate category.*

MedicaidMedicare Part BPrivate InsuranceNo Insurance

Medicaid Provider*

Policy/Member ID #*

Medicaid #*

Group #*

Subscriber ID #*

Responsible Party*

Policy Holder's date of Birth*

Date

Private Insurance Name*

Subscriber ID*

Bin #*

PCN*

Group #*

Please upload the FRONT and BACK of your prescription insurance card for billing purposes.*

Please upload a photo of your chosen identification card*

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 Soleil 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(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Soleil Pharmacy to administer the vaccine(s). If 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. I have acknowledged that I have received the provider's Inc Notice of Privacy Practices which may be provided at my request. For Medicare Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct. I authorize the release of all records to act on this request and I request that payment of benefits be made on my behalf.

Name (Print)*

Signature

Clear

Date

Email

example@example.com

Vaccine Consent & Administration Record

Patient Information

Screening Questions