Book A Vaccine

Patient, Vaccine & Schedule Details

First Name

Last Name

Date of Birth

Phone #

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Gender

Ethnicity/Race

Choice of Vaccine

Schedule Date

Schedule Time

Hours

Minutes

AM/PM

Insurance Details & Authorization

Insurance Provider Name

Card ID

BIN

PCN

Group ID

Medicare Card (MBI, Red, Blue & White Card)

Uninsured (Last four of SSN)

Remarks (Note for Pharmacy)

Medical Checklist

1. Are you pregnant?YesNo

2. Are you currently breastfeeding?YesNo

3. Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any vaccine or injectable therapy, or a history of anaphylaxis due to any cause?YesNo

4. Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any component of a COVID-19 vaccine, including lipid nanoparticles or polyethylene glycol (PEG)?YesNo

5. Have you received any other vaccine within the past 14 days or are scheduled to receive any vaccine in the next 14 days?YesNo

6. Have you received convalescent plasma or monoclonal/polyclonal antibody infusions for COVID-19 within the past 90 days?YesNo

7. Are you under age 16?YesNo

8. Are you currently sick? For example, are you currently experiencing fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, etc.?YesNo

9. Do you have a bleeding disorder or are you taking a blood thinner?YesNo

10. Have you tested positive for COVID-19 in the last 10 days?YesNo

11. Are you currently in quarantine for COVID-19 exposure?YesNo

12. Do you have any health conditions such as heart disease, diabetes or asthma?YesNo

13. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré Syndrome (a condition that causes paralysis) or other nervous system problem?YesNo

14. Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS or transplant)?YesNo

15. Have you received any vaccinations or skin tests in the past four weeks?YesNo

16. Are you currently on home infusions, weekly injections such as Humira™ (adalimumab), Remicade™ (infliximab) or Enbrel™ (etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?YesNo

17. Are you currently taking high-dose steroid therapy (prednisone > 20 mg/day or equivalent) for longer than two weeks?YesNo

18. Have you received a transfusion of blood, blood products or been given a medication called immune (gamma) globulin in the past year?YesNo

19. Are you currently taking any antibiotics, antiviral or antimalarial medications? (Typhoid only)YesNo

20. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)YesNo

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

22. Do you have a nasal condition serious enough to make breathing difficult (e.g., very stuffy nose)?YesNo

23. Have you ever received a dose of COVID-19 vaccine?YesNo

Select Product (If Yes)

Date Of Vaccine

Signature (Initials)

Date

Fill This Form To Book A Vaccine

Patient, Vaccine & Schedule Details

Insurance Details & Authorization

Medical Checklist