I want to receive the following immunization:
*
Shingles
Pneumonia
Tdap (Whooping Cough)
Flu
Other
Appointment
*
Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Gender Identity
*
Race
*
Allergies
*
Address
*
Address
Street Address Line 2
City
State
Zip
Cell Phone
*
Can Receive Text Messages at this number?
*
Yes
No
Email Address
*
example@example.com
Primary Care Provider
*
Address
*
Address
Street Address Line 2
City
State
Postal / Zip Code
Phone
Section B: Insurance information
ID#
Rx BIN#
Rx PCN
Rx Group#
Medicare Part B Medicare Number: (red/white/blue card)
Last 4 digits of SSN
1. Do you feel sick today?
Yes
No
Not Sure
2. Have you ever had a reaction after receiving an immunization, including fainting/dizziness?
Yes
No
Not Sure
Other
3. Do you have a history of allergic reaction to latex, medications, food or vaccines? (Examples: Polyethylene glycol, polysorbate, eggs, bovine protein, gelatin, Gentamicin, polymyxin, neomycin, phenol, yeast, or thimerosal)?
Yes
No
Not Sure
If yes, please list
4. Have you ever had a seizure disorder for which you are on a seizure medications, a brain disorder, Guillain-Barre syndrome or other nervous system problems?
Yes
No
Not Sure
5.Have you ever received the following vaccinations?
Pneumonia
Shingles
Tdap
6.Do you have a condition that weakens the immune system cancer, diabetes, heart disease, immunocompromised, lung disease, kidney disease, obesity, transplant)?
*
Yes
No
Not Sure
If yes, please list
7.For Women: Are you pregnant or considering becoming pregnant in the next month?
Yes
No
Not Sure
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