Vaccine Form

1
Patient Date of Birth* This field is required.Age restrictions may vary depending on state or vaccine
DOB
Month
Day
Year
2
Please select your vaccine(s)* This field is required.
FLU
COVID-19
Pneumonia
FLU HD
Shingles
Tdap
3
Vaccine brand (optional)
Pfizer
Moderna
I don't know
4
Tell us what you need* This field is required.Some vaccines are a series of multiple shots or doses. Tell us which dose you need so we can have it ready. Choose the shingles (Shingrix) dose you need.
1st Dose (I haven't received a dose of this vaccine)
Dose2
I don't know
5
Schedule - dose 1* This field is required.
6
Schedule - dose 2* This field is required.
7
Schedule dose* This field is required.
8
Patient Name* This field is required.
First Name
Last Name
9
Patient Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Phone Number* This field is required.
Please enter a valid phone number.
11
Email* This field is required.
example@example.com
12
Sex assigned at birth* This field is required.
Male
Female
Other
13
Share coverage informationWe need your coverage info, or additional details. if you have them. Sharing accurate information now may save you time onsite. You'll need your insurance card(s). If you don't have insurance, it's ok to continue scheduling your vaccine(s). If you have insurance or Medicare coverage, you'll need to bring your card(s) to your vaccine appointment.
I have Medicare
I have only non-Medicare insurance
I don't have medical insurance, Medicare, Medicaid or any commercial or government-funded health benefit plan.
14
Upload Copy of Medicare Card* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
Provide Copy of prescription insurance* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
16
Please upload a copy of your drivers license or state ID
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Do you have allergic reaction to medications, food, or any ingredients or materials used with vaccine (i.e. aluminum, eggs, bovine protein, gelatin, neomycin, gentamicin, latex,polymyxin, thimerosal, preservatives, etc.)?
Yes
No
18
Please list allergies* This field is required.
Huge
Large
Normal
Small
Ok
Ok
19
Are you feeling sick today?(For example: a cold, fever or acute illness)* This field is required.
Yes
No
20
Do you have any health conditions, such as heart disease, diabetes or asthma?* This field is required.
Yes
No
21
Please indicate your health conditions below* This field is required.
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Large
Normal
Small
Ok
Ok
22
Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularly with vaccines? Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?* This field is required.
Yes
No
23
Have you ever had a seizures, brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?* This field is required.
Yes
No
24
Do you have a bleeding disorder or take blood thinners such as Warfarin/Coumadin?* This field is required.
Yes
No
25
Have you received any vaccinations or skin tests in the past 4-8 weeks?* This field is required.
Yes
No
26
Please list below* This field is required.
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Large
Normal
Small
Ok
Ok
27
Are you currently on home infusions, weekly injections, anticancer drugs or radiation treatments?* This field is required.
Yes
No
28
Are you currently pregnant or breastfeeding or is there a chance you could become pregnant during the next month?* This field is required.
Yes
No
29
We need your consent* This field is required.You're almost done. Provide consent and we'll confirm your appointment.
30
Age of Consent* This field is required.
I hereby declare that I am of legal age and I give my consent with full knowledge and responsibility to the risks and benefits of the vaccine. I have had the opportunity to ask questions and which answers were given to me to my satisfaction.
I am the legal guardian of the above-named patient. I am executing this document on his/her behalf with my full consent and authority. I have had the opportunity to ask questions and by which answers were given to me to my satisfaction.
I am the legal representative of the above-named patient. The patient is of legal age and I am executing this document on his/her behalf. He/she have had the opportunity to ask questions and which the answers were provided to him/her to his/her satisfaction.
31
Patient NameConsent Purpose
First Name
Last Name
32
Date
Date
Month
Day
Year
33
Signature
Clear
34
Review details for Shingles Vaccine
35
Review details for COVID (MODERNA) vaccine
36
Review details for COVID (PFIZER) Vaccine
37
Review details for FLU Vaccine
38
Review details for Pneumonia Vaccine
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