Group:
I do not have insurance
1-2021
Driver's License State # State ID State # Other I do not have ID
Screening Questionnaire and Consent Form
Patient Information:
Patient Name: Date of Birth: Age: Phone#:
Address: City: State: Zip:
Email Address:
Sex at Birth: M or F Which vaccine(s) would you like to receive today?
Ethnicity: Hispanic or Latino (1); Not Hispanic or Latino (2); Unknown (3)
Race: Black or African American (1); White (2); Asian (3); American Indian/Alaska Native (4); Native Hawaiian/Other Pacific Islander (5); Unknown (6)
Medical Conditions: Enter Weight if less than 110 lbs.:
Primary Care Physician (PCP): Dr. Phone:
I authorize the pharmacist to send copies of my vaccine documents to my primary care provider. Yes No
The following questions will help us determine which vaccines may be given today.
Are you sick today? Yes No Don’t Know
Do you have a long term health problem with heart disease, kidney disease, metabolic disorder (e.g. diabetes), anemia or other blood disorders? Yes No Don’t Know
Do you have a long term health problem with lung disease or asthma? Do you smoke? Yes No Don’t Know
Do you have allergies to medications, food (i.e. eggs), latex or any vaccine component? Yes No Don’t Know
Have you received any vaccinations in the past 4 weeks? Yes No Don’t Know
Have you ever had a serious reaction after receiving a vaccination? Yes No Don’t Know
Do you have a neurological disorder such as seizures or other disorders that affect the brain or have had a disorder that resulted from a vaccine? Yes No Don’t Know
Do you have cancer, leukemia, AIDS, or any other immune system problem? Yes No Don’t Know
Do you take prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? Yes No Don’t Know
During the past year, have you received a transfusion of blood or blood products, including antibodies? Yes No Don’t Know
Are you a parent, family member, or caregiver to a new born infant? Yes No Don’t Know
For women: Are you pregnant or could you become pregnant in the next three months? Yes No Don’t Know
Did you bring your Immunization Record Card with you? Yes No Don’t Know
Have you had the following vaccines:
Pneumococcal Vaccine Yes No Don’t Know
Shingles Vaccine Yes No Don’t Know
Whooping Cough (Tdap) Vaccine Yes No Don’t Know
I authorize the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid or other third party payer as needed.
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 15 minutes, after the administration of the immunization.
I acknowledge receipt of the 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 certify my receipt of the services covered by this claim. I request that payment be made on my behalf.
I have read, or have had read to me the Vaccination Information Sheet (VIS) or Emergency Use Authorization (EUA) regarding the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s).
Patient Signature or legal guardian signature
Today’s Date (mm/dd/yy): //
If legal guardian print name
PHARMACY USE ONLY
Lot # Exp. Date Site RA or LA- Circle One
Signature of pharmacist who administered Vaccine(s) and provided VIS to patient:
License #: NPI #: Date:
Signature of Certified Immunizing Technician or Intern who administered Vaccine(s):
Place RX Label Here
Influenza Injectable
Pneumococcal
Hepatitis B
HPV
Varicella
IPV:
Meningococcal
Td
Hepatitis A
MMR
DTaP
Zoster (Shingles)
Tdap
Hepatitis A & B
Other:
