Immunization Screening and Consent Form

First Name *

Last Name *

Middle Initial

Date of Birth *

Age *

Gender *

Home Address *

Contact Phone *

City *

State *

Zip *

Primary Care Physician *

Physician Phone *

Physician Address *

Physician Fax *

The following questions will help us determine your eligibility to be vaccinated today

Are you feeling sick or experiencing a moderate to high fever today?

Yes

Don’t Know

Do you have any allergies to medications, food (i.e. eggs), latex, vaccine component (e.g. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker’s yeast or yeast)?

Yes

Don’t Know

If yes, please list

Have you ever had a serious reaction to any vaccinations, including fainting and feeling dizzy?

Yes

Don’t Know

Have you ever had a health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, or a blood disorder?

Yes

Don’t Know

If yes, please list

Have you ever had a seizure disorder for which the patient is on seizure medication(s), a brain disorder, GuillainBarré Syndrome (a condition that causes paralysis) or other nervous system problem?

Yes

Don’t Know

For women: Are you pregnant or considering becoming pregnant in the next month?

Yes

Don’t Know

LIVE VACCINES (CHICKENPOX, FLU NASAL SPRAY, MMR® II, ORAL TYPHOID, SHINGLES, YELLOW FEVER)

Have you received any vaccinations or skin test within the past four weeks?

Yes

Don’t Know

If yes, please list

Do you have cancer, leukemia, HIV/AIDS, or any other condition that weakens the immune system?

Yes

Don’t Know

During the past year, have you received any transfusion of blood or blood products, or been given a medication called immune (gamma) globulin?

Yes

Don’t Know

Do you take cortisone, prednisone, other steroids, anticancer drugs, or have you had any radiation treatments?

Yes

Don’t Know

Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only)

Yes

Don’t Know

Do you have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose? (For FluMist® only)

Yes

Don’t Know

Pneumococcal Vaccine

Yes

Don’t Know

Shingles Vaccine

Yes

Don’t Know

Tdap (Whooping Cough) Vaccine

Yes

Don’t Know

I certify that I 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 “ ”, 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 I 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, I 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 I do not consent or if I 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 “ ” 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 “ ”, 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 I am financially responsible is due at the time of service.

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Date

NDC

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NASAL

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Pharmacist/Intern Name

Administrative Date

Date VIS Given to Patient

American Indian/Alaska Native	Black/African American
Hispanic/Latino	Native Hawaiin/Other Pacific Islander
White	Asian
Other

Influenza (Injectable)	Hepatitis A & B	Meningococcal
MMR	Influenza (Nasal)	HPV
Td	Varicella	Hepatitis A
Zoster (Shingles)	DTaP	IPV
Hepatitis B	Pneumococcal	Tdap
Hib	Other