Vacine Form

Full Name *
Date of Birth *

Gender

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Phone *
Email *
Address *
Primary Care Provider (PCP) *
PCP Address *
PCP Phone Number *

Are you feeling sick today?

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Do you have any allergies to medication, food (e.g., eggs, yeast), latex, or vaccine components (e.g., neomycin, polymyxin, polyethylene glycol, thimerosal)? *
If yes, please list
Have you ever had an allergic reaction or fainted after receiving a vaccine? *
Do you have a long-term health condition such as heart disease, lung disease, liver disease, asthma, kidney disease, diabetes, anemia, or other blood disorders? *
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problems? *
Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, or Crohn’s disease? *
In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, steroids, chemotherapy, or received radiation treatment? *
Have you ever had a seizure, brain disorder, or Guillain-Barré Syndrome? *
In the past year, have you received a blood transfusion, immune globulin, or antiviral drugs? *
Do you have a bleeding disorder or take blood thinners? *
Has a healthcare provider ever advised you against receiving certain vaccines? *
Are you pregnant or breastfeeding? *

Vaccines Needed: (Check all that apply) ☐ Pneumococcal (13, 15, 20, or 23)

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I understand the benefits and risks of the vaccine(s) as described in the provided EUA/VIS. I have had a chance to ask questions and request the vaccine(s) to be administered to me or the minor for whom I am authorized to sign.

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Date *