Patient Screening Form / Vaccination Receipt

Holmdel Pharmacy Care - Complete this form before your vaccination

Vaccination Details

Date of Vaccination *

Which vaccines would you like to receive during your appointment?

Flucelvax

Seasonal flu vaccine for 4yrs and older

Fluad

Seasonal flu vaccine for 65yrs and older

Pneumonia vaccine

65yrs and older or 18yrs and older with underlying conditions

Shingrix

Shingles vaccines for 50yrs and older or 19yrs and older with underlying conditions

Tetanus Booster (Adacel)

For patients 10yrs to 64yrs (ask your pharmacist to see if you qualify)

RSV VACCINE

Respiratory Syncytial Virus (RSV) - 60 YEARS AND OLDER

Patient Information

Patient Name *

DOB *

Address *

Cell Phone #

Please answer the following questions

Are you sick today? *

Do you have allergies to medications, food, a vaccine component or latex? *

Have you ever had a severe reaction after receiving a vaccination? *

Have you ever had seizure or brain or other nervous system problem? *

Have you ever had Guillain-Barre syndrome within the last 6 weeks? *

Which arm would you like to get the injection on? *

Does the patient authorize this pharmacy to report the administration of this immunization(s) to the Citywide Immunization registry (CIR)?

Does the patient authorize this pharmacy to report the administration of this immunization(s) to their Primary Health Care Provider?

Is there a Health Rx employee that assisted you to this form?

Patient Signature *

Please Sign Above