ALL NON COVID VAX (This Form for Flu Vaccine)

1

Please select an appointment. Use this for all vaccines EXCEPT COVID* This field is required.

2

Name* This field is required.

First Name

Last Name

3

Date of Birth* This field is required.

Date

4

Sex

5

Phone Number

Area Code

Phone Number

6

Vaccine(s) to receive?* This field is required.

Influenza (FLU 2023/2024)

Shingles (Shingrix)

Tetanus (Td)

Tetanus/Pertussis (Tdap - whooping cough)

Hepatitis B

Pneumonia (Prevnar or Pneumovax)

MMR

7

Primary Care Provider (PCP) Name

First Name

Last Name

8

PCP Phone Number

Area Code

Phone Number

9

Are you sick today? If unsure, speak to the pharmacist now.

YESNO

10

Do you have any allergies to medications, food, latex, or a vaccine component?

YESNO

11

Have you ever had a serious reaction after receiving a vaccination?

YESNO

12

Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?

YESNO

13

Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder?

YESNO

14

Do you take cortisone, prednisone, other steroids, anticancer drugs or any anticoagulation medications (Warfarin, Coumadin or blood thinners), or have you had radiation treatments?

YESNO

15

Have you had a seizure, brain, or other nervous system problem?

YESNO

16

During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?

YESNO

17

Have you received any vaccinations in the past 4 weeks?

YESNO

18

Was this form completed by someone OTHER THAN the patient?

YESNO

19

Form completed by?

First Name

Last Name

20

SignatureBy signing you agree to the Consent to Vaccination.

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