New COVID-19 Vaccine Screening Form

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

First NameLast Name

Date of Birth*

Age*

Gender*

Phone Number*

Home Address*

Street Address

Apt #

CityState Initials

Zip Code

Are you affiliated with a company? if yes please provide the name of the company below.

Which Vaccine(s) would you like to receive today?*

Medical Conditions:*

Enter Weight if less than 110 lbs

** For EMERGENCY USE ONLY *

Primary Doctor

Phone Number of Primary Doctor

Alternate Doctor

Phone Number of Alternate Doctor

I authorize the pharmacist to send copies of my vaccine documents to my primary care provider

YesNo

Would you like us to bill your insurance ( at no charge) at home Covid-test kit for you

YesNo

Patient Email

By providing your email address you are agreeing to receive special offers, discount and information via email from AR-EX Pharmacy. You may opt out of the email communication at any time. AR-EX Pharmacy values your privacy. As a result, we will never share or sell your information with any outside manufactures or marketers.

Do you have health insurance (Medical and Pharmacy):*

YesNo

Regular Flu Shot : $29.99

High Dose Flu Shot for ages 65 and up: $75.00

Pharmacy Card : Rx Bin#

Rx PCN#

Rx Group #

Rx Id #

Medical Insurance Name

ID#

Group #

Medicare Part B# (if applicable)

Upload Medical and Pharmacy Insurance Card

The following questions will help us determine which vaccines may be given today. If a question is not clear, please ask your pharmacist to explain it.

	Yes	No	Don't Know
Are you feeling sick today?
Do you have Allergies to medications, food (i.e. eggs), latex or any vaccine component (i.e. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker's yeast or yeast)?
Have you ever had a serious reaction after receiving a vaccination ?
Have you received any vaccination in the past 4 weeks?
Do you have a neurological disorder such as seizures or other disorders that affect the brain or have had a disorder that resulted from a vaccine (i.e. Gullain-Barre Syndrome)?
For Women: Are you pregnant or could you become pregnant in the next three months?
For Patients Over 65 OR Have a chronic condition such as Asthma or COPD OR Smoke: Have you received the Pneumococcal or "Pneumonia" Vaccine
Do you have cancer, Leukemia, AIDS, or any other immune system problem?
Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had X-ray treatments:
During the past year , have you received a transfusion of blood or blood products, including antibodies?

If you have answered yes to any of the above question(s) then explain below

I authorize the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid or other third-party payer as needed and request payment of authorized benefits to be made on my behalf to AR-EX Pharmacy.

I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine.
I acknowledge that my vaccination record may be shared with federal or state agencies for registry reporting.
I acknowledge that the pharmacist recommends that vaccinated patient should remain in the waiting area, after the administration of the immunization, for 20 minutes.
I have read, or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccines(s). I consent to, or give consent for, the administration of the vaccine(s). I fully release and discharge AR-EX Pharmacy, affiliate their officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.

Patient signature (Parent or guardian, if minor):

Date Signed

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

Date

Screening Questionnaire, Consent and Physician Fax Form