Flu Clinic Vashon Pharmacy Immunization Screening Form

1
Sign-up for TDAP Vaccination Clinics:

McMurray Middle School - Thursday May 21, 2026 - 8am

Chautauqua Elementary School - Thursday May 21, 2026 - 9am

Sign-up deadlines:

Noon on Wednesday May 20, 2026 at Noon
2
Name of patient* This field is required.
First Name
Last Name
3
Date of Birth of patient* This field is required.
Date
Month
Day
Year
4
Email address of parent/guardian* This field is required.This email will be used to communicate regarding your child's appointment
example@example.com
5
Does the patient have any allergies?Please list them below, leave blank if you have none.
6
Phone Number of parent/guardian* This field is required.
Area Code
Phone Number
7
Address of parent/guardian* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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
8
Race* This field is required.Required by state for registry upload
Asian
Native American or Alaskan Native
White/Caucasian
Black/African American
Other/Prefer not to say
9
Ethnicity* This field is required.Required by state for registry upload
Hispanic or Latino
Not Hispanic or Latino
Other/Prefer no to say
10
Please enter the patient's prescription insurance information below. If the patient has no insurance, please enter "no insurance" in the top boxPlease provide the RX Group and/or RX PCN numbers if they are shown on the patient's insurance card.
Patient ID #
BIN #
RX Group #
RX PCN#
11
Do you have a red/white/blue Medicare ID card? (patients over 65 and/or eligible for medicare have this)IF yes, we will ask for the ID number off that card to bill Flu and Pneumonia vaccinations, all other vaccines go through drug plans typically if covered.
YESNO
12
Medicare ID #Please provide the number off of your Red-White-Blue Medicare card if applicable.
13
Is the patient sick today?* This field is required.
YESNO
14
Which vaccine(s) does this patient wish to receive today? (Patients may receive Covid and Flu vaccines at the same time.)PLEASE NOTE: All vaccinations will be test-billed to insurance prior to the clinic. For patients without insurance, flu vaccinations will be provided free of charge, paid for by donations to VashonBePrepared. In addition, subject to availability of donated funds, COVID vaccinations may also be provided free of charge.
Flu Vaccine
Covid Vaccine
15
Has the patient ever had a serious reaction to a vaccine?* This field is required.(Needed medical attention, difficulty breathing, severe rash or hives, etc...)
YESNO
16
Does the patient have any long-term health conditions?* This field is required.If yes, pharmacist may discuss them with the parent/guardian depending on the vaccine being administered.
YESNO
17
Does the patient have cancer, AIDS/HIV, Leukemia or any other immune system related condition?* This field is required.
YESNO
18
Has the patient had Covid-19 in the past 90 days, received immunoglobulin or other injectable treatment for Covid-19 or any other illness?
YESNO
19
Has the patient had a seizure, brain or other nervous system problem?* This field is required.
YESNO
20
Please enter the date of the patient's last covid vaccination. LEAVE BLANK IF LAST VACCINATION WAS PRIOR TO CURRENT YEAR.If date is less than 2 months prior to the vaccination date, the covid vaccine cannot be administered.
Date
Year
Month
Day
21
Select the clinic the patient will be attending* This field is required.Patients will be vaccinated upon arrival at school. Due to staggered bus routes and patient drop off, we will be able to spread out the vaccinations sufficiently.
McMurray Middle School - 8am on May 21st
Chautauqua Elementary School - 9am on May 21st
22
Please select a vaccination appointment below
23
Signature - please sign in the box below. (Some formats will require you to scroll down. If using a computer use mouse to draw signature.) Signature by a parent/guardian is required for patients younger than 18.* This field is required.I acknowledge that my vaccination record may be shared with federal or state or city agencies for registry reporting. I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area, for 10 minutes, after the administration of the immunization. I acknowledge receipt of Vashon Pharmacy’s Notice of Privacy Practices for Protected Health Information. I acknowledge that the administration of an immunization or vaccine does not substitute for an annual check-up with the patient’s primary care physician. 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 vaccine(s). I consent to, or give consent for, the administration of the vaccine(s). I fully release and discharge Vashon Pharmacy, its affiliates, officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.
24
Parent or Guardian Name
First Name
Last Name
25
Is the patient's prescription insurance on file and up-to-date with Vashon Pharmacy?* This field is required.Answer NO if the patient has no insurance.
YESNO
Should be Empty: