General Vaccine Screening Form

General Vaccine Consent Form
Patient Name (if patient is a child, please enter the Child's Name)*

First NameLast Name
Home Address*

Street Address

Apt #

CityState Initials

Zip Code
Date of Birth*

MonthDayYear
Age
Gender*

MaleFemale
Gender
Race

American Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderBlack or African AmericanWhiteUnknownOther
Race
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoUnknown
Ethnicity
Phone Number*
Email
to receive PDF email of this form, not necessary to bring it (pdf password Vaccine#1
Last 4 digits of Social Security Number or Medicare Number
Which Vaccine are coming for today?

Influenza (Flucelvax, Fluad)Meningococcal (Menquadfi)Herpes Zoster (Shingrix)Hepatitis A (Havrix)Hepatitis B (Engerix-B)Tetanus, Diptheria, Pertussis (Adacel, Boostrix)Measules, Mumps, Rubella (M-M-R II)Pneumococcal (Prevnar20, Pneumovax 23, Prevnar 13)Human Papillomavirus (Gardasil 9)
Which arm would you like to get the injection on*

Left ArmRight Arm
Pediatrician/Provider Name & Fax Number*
We will fax record of vaccine to pediatrician for children
1. Is the person to be vaccinated sick today?*

YesNo
2. Does the person to be vaccinated have any allergies to medications, food, a vaccine component, or latex?*

YesNo
3. Has the person to be vaccinated ever had a serious reaction after receiving a vaccination in the past?*

YesNo
4. Has the person to be vaccinated ever had Guillain-Barré syndrome?*

YesNo
5. Does the person have any long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?*

YesNo
6. Does the person have cancer, leukemia, AIDS, or any other immune system problem?*

YesNo
7. Does the person take cortisone, prednisone, other steroids, or anti-cancer drugs, or have you had radiation treatments?*

YesNo
8. Has the person had a seizure or a brain or other nervous system problem?*

YesNo
If yes, please list
9. During the past year, has the person received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

YesNo
10. For women: Is the person pregnant or is there a chance she could become pregnant during the next month?*

YesNo
11. Has the person received any vaccinations in the past 4 weeks?*

YesNo
12. Have you treated with antibody therapy specifically for COVID-19 (monoclonal antibodies or convalescent plasma)?

YesNo
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 Insurance Card (optional)

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

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Please Upload Supporting Uninsured Document

Cancelof
Patient signature (Parent or guardian, if minor):*

Clear
Date Signed

MonthDayYear
Date
For minor, please provide Parent or Guardian's Full Name

First NameLast Name
For minor, please provide Parent or Guardian's Date of Birth

MonthDayYear
Date
Clinic
1.On your HORIZON as Medical Insurance, please enter the ID Number on your card blanks
2.Who is the Primary Cardholder (First/Last Name)blank
Pharmacist Name
First and Last Name
Pharmacist Signature

Clear
Immunizer Name
First and Last Name
Immunizer Signature

Clear
Lot Number
Expiration Date:
Vaccine Manufacturer

ModernaPfizerPfizer PediatricJanssen
Pharmacy Name
Pharmacy NPI*
Do you have health insurance (not required for COVID vaccines):

YesNo
By signing below I attest that I do not have any medical or pharmacy insurance. (optional)

Clear
Please upload a Photo ID such as driver license or passport copy if available. (By uploading your ID now will reduce your wait time in the pharmacy) Please also bring in original at time of vaccination (optional).

Cancelof
Please upload a picture of your prescription insurance card if available. (By uploading your insurance card now will also reduce your wait time in the pharmacy) Please also bring in original at time of vaccination (optional).

Cancelof
Calculation
Bring with you: PHOTO ID & INSURANCE CARD
After pressing SUBMIT, you are finished and will be redirected to a GOOGLE REVIEW page, and if you entered an email, will receive a copy of the Pre-Vaccination Checklist for your records.
Should be Empty:

General Vaccine Consent Form

Bring with you: PHOTO ID & INSURANCE CARD