Immunization Screening & Consent (Non-Covid)

NEW CITY PHARMACY

Immunization Screening & Consent Form

Date of Birth *

Date

Last Name

First Name

Middle Initial

Gender *

Address *

Address

Street Address Line 2

City

State

For Persons Under 19 Years Old, Mother's Maiden Name

NYSIIS Permission 19 Years Old

No Yes

Vaccine to be Administered *

Quadrivalent Flu (12+) Quadrivalent High Dose (65+) Shingrix (Zoster)

Appointment *

Doctor's Name

Health Insurance Provider *

Policy Number *

Clinic/Office Site Where Vaccine Administered

Please complete the questions below for yourself or the person receiving the vaccine.

Are you currently sick with fever? *

No Yes

Have you ever had a life threatening allergy to any component (or part) of the flu or pneumonia vaccine? *

No Yes

If yes, please describe

Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving flu vaccine? *

No Yes

Are you a smoker or have a chronic medical condition such as asthma, heart or lung disease? *

No Yes

Have you ever had a pneumonia shot? *

No Yes

Are you a child or adolescent receiving long-term aspirin therapy? *

No Yes

Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care? *

No Yes

Have you taken an antiviral medication for the flu within the last 48 hours? *

No Yes Type option 3

Have you ever had a severe life threatening allergy to eggs or egg products? *

No Yes

I have read, or had explained to me, the Vaccine Information Statement about influenza vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. I request that the influenza vaccination be given to me (or the person named above for whom I am authorized to make this request I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights.

I have read, or had explained to me, the Vaccine Information Statement about pneumococcal vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. I request that the pneumococcal vaccination be given to me (or the person named above for whom I am authorized to make this request I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights.

Signature of Recipient (Parent or Guardian)

Clear

Date