MCP- Vaccine Appointment Form

Name*

First NameLast Name

Gender*

FemaleMale

Date of Birth*

Date

Age*

Please enter your Medicare ID number if you are over the age of 65 (xxxx-xxx-xxxx)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Which vaccine(s) would you like to receive?*

Are you sick today?*

YesNo

Have you had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine?*

YesNo

Do you carry an Epi-pen for emergency treatment of anaphylaxis?*

YesNo

Do you have allergies or reactions to any medications, foods, vaccines or latex?*

YesNo

If yes, please explain:

Have you received any other vaccinations in the past 14 days?*

YesNo

In the past 90 days, have you received monoclonal antibodies or been diagnosed with COVID-19?*

YesNo

In the past 10 days, have you had fever, chills, cough, shortness of breath, fatigue, headache, new loss of taste and/or smell, nausea, vomiting or diarrhea?*

YesNo

Are you immunocompromised or on a medicine that affects your immune system?*

YesNo

Do you have a bleeding disorder or are you on a blood thinner?*

YesNo

Do you have a history of Guillain-Barré syndrome?*

YesNo

For women, are you pregnant or is there a chance you could become pregnant?

YesNo

For women, are you breastfeeding?

YesNo

Appointment*

I GIVE CONSENT to the Pine Hill Pharmacy and its staff to vaccinate me with this vaccine.

I FULLY UNDERSTAND THAT I WILL BE ULTIMATELY RESPONSIBLE FOR ANY CHARGES if I am not a covered person under the insurance plan (program listed above), the services are not covered services, or any co-pays, deductibles or coinsurance obligations apply. Massachusetts law (M.G.L. c. 111, Section 24M) requires providers to report immunization information to a computerized immunization registry known as the Massachusetts Immunization Information System (MIIS). The MIIS stores immunization records for you and your healthcare provider and can help prevent outbreaks of disease like measles and the flu. All information in the MIIS is kept secure and confidential. The MIIS allows information to be shared with health care providers, school nurses, local boards of health, state agencies concerned with immunization and Health plans for immunization rate improvement and quality improvement efforts for each plan’s membership. You have the right to object to the sharing of your immunization information across providers in the MIIS. For more information, please ask your healthcare provider, visit the MIIS website at www.mass.gov/dph/miis or contact the Massachusetts Immunization Program MIIS Help Desk directly at 617-983-4335.

Signature*

Vaccine Appointment Form

Patient Information

Vaccine Information

Screening Questionnaire

Select Appointment Time