Magnolia Pharmacy Immunization Screening Form

Patient Name

Date of Birth

Date

Phone

Address

Street Address Line 2

City

Zip

Primary Physician

Vaccination Screening Questionnaire

	Yes	No	Don't Know
1. Are you feeling sick or experiencing moderate to high fever today?
2. Do you have any allergies to medications, food (i.e. eggs), latex, vaccine components (e.g. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker's yeast, or yeast)?
3. Have you ever had a serious reaction to any vaccinations, including fainting and feeling dizzy?
4. Have you ever had a health problem with lung, heart, kidney, or metabolic disease (e.g. diabetes), asthma, or a blood disorder?
5. Have you ever had a seizure disorder for which the patient is on seizure medication(s), a brain disorder, Guillain-Barre Syndrome (a condition that causes paralysis) or other nervous system problem?
6. Are you taking biological injectables, steroids, anticancer drugs, antivirals, or have any condition that affects your immune system?
7. For women: Are you pregnant or considering becoming pregnant in the next month?

If you answered yes to question #2, please list:

If you answered yes to question #4, please list:

COVID-19 Screening Questionnaire

	Yes	No	Don't Know
Do you have a fever or above-normal temperature (>100.4 F)?
Are you experiencing shortness of breath, a dry cough, or having trouble breathing?
Have you experienced any of the above in the last 14 days?
Have you been in contact with anyone who has tested positive for COVID-19 in the last 14 days?
Have you traveled more than 100 miles from your home in the last 14 days?

Acknowledgement:

I certify that am: (a) the patient and at least 18 years of age or (b) the parent or legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Magnolia Pharmacy, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself, my heirs and personal representatives, | hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that I understand the purposes/benefits of my state's immunization registry ("State Registry") and the Provider may disclose my immunization information to the State Registry. I acknowledge that, depending upon my state's law, I may prevent the disclosure of my immunization information by the applicable Provider to the State Registry by using the opt-out form. The Provider will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state's law, I may need to specifically consent, and to the extent required by my state's law, by signing below, I hereby do consent to the Provider reporting my immunization information to the State Registry. I understand that even if do not consent or if withdraw my consent, my state's laws may permit certain disclosures of my immunization information as required or permitted by law. I voluntarily authorize and direct my healthcare provider at Magnolia Pharmacy to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated at Magnolia Pharmacy, my Primary Care Physician, my insurance and/or state or federal registries, where required, for the purpose of treatment, payment or other healthcare operations. I further agree to be fully financially responsible for any cost sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which am financially responsible is due at the time of service.

Signature

Date

18230 FM 1488 Suite 100 Magnolia, TX 77354(281) 356-9089NPI: 1003807843