Immunization Screening & Consent Form
Immunization Site:
*
Please Select Location
In Store (Monday- Friday 10:00am - 5:00pm & Saturday 10:00am-1:00pm)
Immunization Screening & Consent Form
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Current Date
/
Month
/
Day
Year
Date
Age - days
Age
Gender
*
Female
Male
Unknown
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Ethnicity
*
Not Hispanic or Latino
Hispanic or Latino
Race
*
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Black or African American
White
Other Race
Address
*
Home Address
Street Address Line 2
City
State
Zip
Mother's Maiden Name
*
First Name
Last Name
I want to receive the following immunization(s):
*
Inactivated Influenza (Flu)
Pneumonia
Shingles
Tdap (Whooping Cough)
COVID-19 2025-2026
RSV
Preferred Arm
*
Right
Left
COVID-19 series
Primary
Booster
COVID-19 immunization company
Pfizer
Please answer the following questions to help us decide if you can get a vaccination today:
*
Rows
YES
NO
Are you currently sick with a moderate to high fever, vomiting/diarrhea?
Have you ever fainted or felt dizzy when receiving an immunization?
Have you ever had a serious reaction after receiving an immunization?
Do you have allergies to medications, food, or vaccines? (examples: eggs, bovine protein, gelatin, gentamycin, polymyxin, neomycin, phenol, yeast, or thimerosal) If yes, please list below:
Have you ever had a seizure disorder for which you are on seizure medications(s), a brain disorder, Guillain-Barre syndrome, or other nervous system problem?
Are you 65 years of age or older?
Do you smoke, use e-cigarettes, or vape?
Have you ever had a pneumonia vaccination?
Have you ever tested positive for COVID-19?
Have you received convalescent plasma or monoclonal antibody infusion within the last 90 days?
Questions? Do you have any questions you would like to ask the pharmacist?
Do you have a chronic condition or long-term health problem? If yes, please check all that apply below:
Chronic condition or long-term health problem
Anemia
Asthma
Diabetes
Heart Disease
Liver Disease
Lung Disease
Other
Allergies:
*
If you do not have any, type NONE.
I give permission to the Providence Community Pharmacy pharmacist, Certified Pharmacy Tech or the intern to give me the vaccines(s) I
have check marked.
I understand the risks and benefits associated with the vaccines(s) I am getting. I have received, read and/or had
explained to me the Vaccine Information Statements on the vaccine(s) I am getting. I have had a chance to ask
questions and I understand the answers.
I understand that it is not possible to predict all the possible side effects or complications associated with the
vaccine(s) I am getting.
I give permission for Providence Community Pharmacy to give information to Medicare, Medicaid, or any other
insurance I have to help pay my bill. I allow Medicare, Medicaid and any other insurance I have to pay
Providence Community Pharmacy. I know that I will have to pay any bills that Medicare, Medicaid or my other
insurances do not pay.
I
accept responsibility for seeking medical attention for any problems with this vaccination.
What is your requested appointment date and time?
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Month
/
Day
Year
Date
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5
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9
10
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12
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Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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