Seasonal Vaccines 2022 - Pre-Vaccination Screening Checklist

I am interested in the following vaccine(s):*

Hepatitis A (Ages 13+)Hepatitis B (Ages 13+)HPV (Gardasil®) (Ages 13-26)Shingles (Shingrix®) (Ages 50+)Pneumococcal (Ages 65+)Meningococcal (Menquadfi®) (Ages 13-21)Tdap (Tetanus, Diptheria + Pertusis) (Ages 13+)Meningitis B (Trumenba)(Ages 16-23)Influenza (Ages 6+)

Schedule Your Appointment*

Vaccine Recipient Name*

First NameLast Name

Date of birth*

Date

Age*

Gender*

MaleFemale

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code

Do you have a Medicare Card?*

Yes, I have a Medicare Card.No, but I have Health Insurance.I do not have Health Insurance.

Medicare Card #*

9999-999-9999

Insurance ID - Upload Insurance/Other Card Photo

Patient Phone*

Email

Please enter email, so we can send you an email reminder about your upcoming appointment. Only for appointments scheduled online.

1. Are you feeling sick or experiencing a moderate to high fever today?*

YesNoDon't Know

2. Do you have any allergies to medications, food (i.e. eggs), latex, vaccine component (e.g. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker's yeast or yeast?)*

YesNoDon't Know

If yes, please list: blanks

3. Does the person to be vaccinated have a long-term health problem with heart disease, lung disease (including asthma), Kidney disease, neurologic disease, liver disease, or metabolic disease (e.g., diabetes)?*

YesNoDon't Know

If yes, please list: blanks

4. Have you ever had a seizure disorder for which a patient is on seizure medication(s), a brain disorder, Guillain-Barré Syndrome (a condition that causes paralysis) or other nervous system problem?*

YesNoDon't Know

5. For women: Are you pregnant or considering becoming pregnant in the next month?*

YesNoDon't Know

FLU NASAL SPRAY (FLUMIST QUADRIVALENT): 1. Have you received any vaccinations or skin test within the past four weeks?*

YesNoDon't Know

If yes, please list: blanks

FLU NASAL SPRAY (FLUMIST QUADRIVALENT): 2. Does the person to be vaccinated have a)an open channel between the cerebrospinal fluid (CSF) and the mouth, throat, nose or ear or any other cranial CSF leak, or b) a cochlear implant, or c) an immunocompromising condition due to any cause (e.g., medication, congenital or acquired immunodeficiency, HIV infection, or a missing or non-functioning spleen [e.g., caused by sickle cell disease]?*

YesNoDon't Know

FLU NASAL SPRAY (FLUMIST QUADRIVALENT): 3. Is the person to be vaccinated currently taking influenza antiviral medications, or have they taken any in the past 3 weeks?*

YesNoDon't Know

FLU NASAL SPRAY (FLUMIST QUADRIVALENT): 4. Does the person to be vaccinated have an allergy to an ingredient of the influenza vaccine?*

YesNoDon't Know

FLU NASAL SPRAY (FLUMIST QUADRIVALENT): 5. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?*

YesNoDon't Know

FLU NASAL SPRAY (FLUMIST QUADRIVALENT): 6. Are you receiving aspirin therapy or aspirin(salicylate-containing medicine)? (18 years of age and younger only)*

YesNoDon't Know

FLU NASAL SPRAY (FLUMIST QUADRIVALENT): 7. Do you have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose?*

YesNoDon't Know

FLU NASAL SPRAY (FLUMIST QUADRIVALENT): 8. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)?*

YesNoDon't Know

I certify that I am: (a) the patient and at least 18 years of age or (b) the parent or legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of "Mackenthun Beck Pharmacy, Inc", to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or
unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that I understand the purposes/benefits of my state’s immunization registry (“State Registry”) and the Provider may disclose my immunization information to the State Registry. I acknowledge that, depending upon my state’s law, I may prevent the disclosure of my immunization information by the applicable Provider to the State Registry by using the opt-out form. The Provider will, if my state permits,
provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically consent, and to the extent required by my state’s law, by signing below, I hereby do consent to the Provider reporting my immunization information to the State Registry. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my immunization information as required or permitted by law. I voluntarily authorize and direct my healthcare provider at "Mackenthun Beck Pharmacy, Inc" to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated at "Mackenthun Beck Pharmacy, Inc", my Primary Care Physician, my insurance and/or state or federal registries, where required, for the purpose of treatment, payment or other healthcare operations. I further agree to be fully financially responsible for any cost sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that
any payment for which I am financially responsible is due at the time of service.

Patient (or Guardian) Name*

First NameLast Name

Patient (or Guardian) Signature*

Clear

Date*

Date

Immunization Registration

Attention:

Immunization Screening & Consent Form