Immunization Screening Form

Immunization Consent Form

In order to receive the vaccine, you must fill the below form
Vaccine Screening Questionnaire

Please Answer by checking Yes or No

	Yes	No
Have you been sick and/or had a fever of 101 degree F today or in the past 48 hours?
Have you ever had an allergic reaction to another vaccine or any injectable medication?
Have you ever had an allergic reaction to Food, Medication, latex or any food or medication additives?
Do you have (or is there a risk that you have) cancer, leukemia, HIV, AIDS or any other immune system problem?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments
Have you had a seizure or other neurological problems
Do you have a bleeding disorder or are you taking a blood thinner (Baby Aspirin, Eliquis or other) If Yes, Please list:----------------------------------------------
During the past 12 months, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
Have you received any vaccinations in the past 4 weeks?
For women: Are you pregnant or is there a chance that you could become pregnant during the next 30 days?
For women: When was the first day of your last menstrual period?

Please list all medication, vaccine, food or ingredients that you are allergic to
Please list any medication or any health condition that might suppress your immunity
Select an appointment time *
Please list any blood thinners you might be taking
Vaccine Recipient Name *

First Name Middle Name Last Name
Vaccine Recipient Physical Address *

Street Address

Apt #

City State Initials

Zip Code
Date of Birth *

Month Day Year
Gender at birth *
Race *
Ethnicity *
Vaccine Recipient Phone Number *
Mother's Maiden Name *
Required for proper vaccine documentation
Primary Care Provider Name
Name of Parent/Guardian *
Relationship to Vaccine Receipient *
Phone Number of Parent/Guardian *
Email
example@example.com
Vaccine Screen Questions*

The following questions will help us determine which vaccines you may be given today.
- If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked.
- If a question is not clear, please ask your healthcare provider to explain it
Which arm would you like to get the injection on *

Left Arm Right Arm
Please select your Vaccine *

Influenza (Flu) Pneumococcal Polysaccharide PPSV23 (Pneumonia) Pneumococcal Conjugate PCV13 (Pneumonia) Meningococcal (MenB) Meningococcal ACWY (Meningitis) Varicella (Chickenpox) Measles, Mumps & Rubella (MMR) Measles, Mumps, Rubella & Varicella (MMRV) Tetanus, Diphtheria, & Pertussis (TDaP or DTaP) Influenza (Flu) Senior (+65 Years) Hepatitis A Hepatitis B Yellow Fever Typhoid Human Papilloma Virus (HPV) Tetanus and Diphtheria (Td) Zoster/Shingles (Live) Zoster/Shingles (Recombinant)

Consent (check each box below after reading and prior to signing the form) *

	Check each box
I understand the benefits and risks of the vaccine as described in the Fact Sheet (the Fact Sheet is available after clicking submit), a copy of which I might be provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I GIVE CONSENT to the PARK RIDGE PHARMACY and its staff to vaccinate me with this vaccine.
I FULLY UNDERSTAND THAT I WILL BE ULTIMATELY RESPONSIBLE FOR ANY CHARGES if I am not a covered person under the insurance plan (program listed above), the services are not covered services, or any co-pays, deductibles or coinsurance obligations apply.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.

If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs. If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.
Please Upload driver's license or any form of ID

Cancel of
Please Upload Prescription Insurance Card

Cancel of
Please Upload Medical Insurance card and Medicare card

Cancel of
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security Number State identification number and state of issuance Driver's license number and state of issuance
Please Upload Supporting Uninsured Document

Cancel of
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear
Date Signed

Month Day Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature

Clear
Immunizer Name
First and Last Name
Immunizer Signature

Clear
Lot Number
Expiration Date:
Pharmacy Name
Pharmacy NPI *
Should be Empty:

Immunization Consent Form

Vaccine Screening Questionnaire