OC103 Immunization Questionnaire

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Screening Questionnaire for Immunization and Consent
Medicare #: Click here to enter text.
Patient Name
Address
Gender
Male
Female
Cash
DOB
Phone #
City, State
Zip
Medical Conditions
Weight
The following questions will help us determine which vaccines may be given today. If a question is not
Yes
No
clear, please ask your pharmacist to explain the question.
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10.
Are you sick today?
Do you have allergies to medications, food (ie eggs) or any vaccine?
Have you ever had a serious reaction after receiving a vaccination?
Do you have cancer, leukemia, AIDS, or any other immune system problem?
Do you take cortisone, prednisone, other steroids, or anticancer drugs or
have you had X-ray treatments?
During the past year, have you received a transfusion of blood or blood
products, or been given a medicine called immune (gamma) globulin?
For women: Are you pregnant or is there a chance you could become
pregnant in the next three months?
Have you received any vaccinations in the past 4 weeks?
Do you have a neurological disorder such as seizures or other disorders that
affect the brain or have a neurological disorder that resulted from a vaccine?
Did you bring your Immunization Record Card with you? Yes
It is important for you to have a personal record of your vaccinations. If you don't have a record card,
ask your pharmacist to give you one. Bring this record with you every time you seek medical care.
31654 Rancho Viejo Road, Unit N, San Juan Capistrano, CA 92675 Phone: (949) 429-5326 Fax: (949) 429-5328
[email protected]
www.ocpharmacy.net
Don't know
Which Vaccines would you like to receive today?
 Influenza - VIS Date: Click here to enter text.
 Pneumococcal - VIS Date: Click here to enter
text.
 Hepatitis B - VIS Date: Click here to enter
text.
 HPV - VIS Date:
text.
Click here to enter
 Varicella - VIS Date: Click here to enter text.
 Meningococcal - VIS Date: Click here to
enter text.
 Td - VIS Date: Click here to enter text.
 Hepatitis A - VIS Date: Click here to enter
text.
 MMR - VIS Date: Click here to enter text.
 Zoster (Shingles) - VIS Date:

Click here
to enter text.
Tdap - VIS Date: Click here to enter
text.
 Hepatitis A & B - VIS Date:
enter text.
 Live, Influenza - VIS Date:
enter text.
Click here to
Click here to
 Other: Click here to enter text.-VIS Date:
Click here to enter text.
I have answered , or have had read to me the vaccination information sheet (VIS) regarding the vaccine(s) marked above. I have had the opportunity to ask
questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of
the vaccine(s) marked above and the notification of my primary care physician. I fully release and discharge OC Pharmacy, its affiliates, and their officers,
directors, and employees from any liability fo rillness, injury, loss, or damage which may result there from.
Patient Name (Print):_________________________________________Patient Signature________________________________________________
if not the patient, this form was completed by: _________________________________Relation to the patient:________________________________
Medicare Part B Customers: I authorize the release of any medical or other information necessary to process this claim. I also request payment of
government benefits either to myself or to the party who accepts assignment below.
Patient Signature________________________________________________
Manufacturer:
Lot#:
Manufacturer:
Lot#:
Manufacturer:
Lot#:
Exp Date:
Exp Date:
Exp Date:
Site of Vaccination:
Site of Vaccination:
Site of Vaccination:
31654 Rancho Viejo Road, Unit N, San Juan Capistrano, CA 92675 Phone: (949) 429-5326 Fax: (949) 429-5328
[email protected]
www.ocpharmacy.net
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