Which vaccine(s) would you like to receive today? - Kinney Drugs

Kinney Drugs Immunization Screening, Consent & Administration Record
Patient Name: ____________________________ Address: _______________________________________ DOB: ______________
Primary Provider:____________________________________________________________________________________________
The following questions will help us determine which vaccines you may be given today. If you answer “yes” to any question, it does not
necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your
pharmacist to explain it. Yes No Don’t Know
1. Are you sick today?
2. Do you have allergies to medications, food (ie.eggs), latex or any vaccine?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have a long‐term health problem with lung disease, heart disease, asthma, kidney
disease, metabolic disease (e.g., diabetes), anemia or other blood disorder?
5. Do you have cancer, leukemia, AIDS, or any other immune system problem?
6. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had
X‐Ray treatments?
7. During the past year, have you received a transfusion of blood or blood
products, been given a medicine called immune (gamma) globulin, or an antiviral drug?
8. Have you had a seizure, brain, or other nervous system problem?
9. Are you pregnant or is there a chance you could become pregnant in the next 3 months?
10. Have you received any vaccinations in the past four (4) weeks?
11. Did you bring an Immunization Record Card with you?
Which vaccine(s) would you like to receive today?
Influenza‐ VIS date:____________ Zoster‐VIS date:______________ Other (list)‐ VIS date:____________
I have read, 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 acknowledge that the pharmacist recommends that
vaccinated patients remain in the waiting area after the administration of the immunization for 15 minutes. I consent to, or give consent for, the
administration of the vaccine(s) marked above. I fully release and discharge Kinney Drugs, Inc. , its affiliates, directors, and employees from any liability for
illness, injury, loss, or damage which may result. I further agree to be financially responsible for any copay or co‐sharing amount not covered by my
insurance at the time of service.
I authorize the pharmacist to send copies of my vaccine documentation to my primary care provider.
I prohibit the pharmacist from sending copies of my vaccine documentation to my primary care provider.
Patient Name (Print):______________________________Patient Signature:_________________________________
If not the patient, this form was completed by: ________________________________ Relationship:______________
Vaccine: ______________________
Manufacturer: _________________
Lot # _________________________
Exp Date: _____________________
Site & Dose: ___________________
Vaccine: ________________________ Epinephrine (if required): __________
Manufacturer: ___________________ Manufacturer: ___________________
Lot # ___________________________ Lot # __________________________
Exp Date: _______________________ Exp Date: _______________________
Site & Dose: _____________________ Site & Dose: _____________________
Signature of RPh who administered vaccine(s):__________________________ Lic # ____________Date __________
Kinney Drugs #______________ Address _____________________________________________________________
The information transmitted in this fax contains confidential patient information which is legally protected under HIPAA. Any retransmission, dissemination
or other use of this information by persons other than the intended recipient is prohibited. If this information was received in error, please notify us
immediately and return the original message to us at the above address. Revised September 2011

FAX
Physician Notification of Vaccination Letter
Dear Doctor or Nurse at : _____________________________________
Patient’s Primary Care Provider / Clinic
Address: __________________________________________________
Phone #: __________________________________________________
Fax #: ____________________________________________________________________________________
We have recently provided vaccination services to one of your patients. A Vaccine Administration
Record was filled out and given to the patient. We want to make certain that you, too, have this
information so that you can update your patient’s medical record. Please contact us if you have
any questions about this information.
Patient’s Name: _____________________________ Patient’s Birthdate: __________________
The vaccines that were given on ___________________ are checked below.
Date
Influenza (injectable)
Influenza (intranasal)
Zoster (shingles)
Other ___________________________
Other ___________________________
Other ___________________________
Provider: Kinney Drugs # ____________
Address: ___________________________________________________
City, State, Zip: ______________________________________________
Contact Person: _____________________________________________
Phone Number: _____________________________________________
Confidential Patient Information
The information transmitted in this FAX is intended only for the person or entity to whom it is addressed and contains
Confidential Patient Information and must be handled accordingly. Any retransmission, dissemination or other use of this information
by persons other than the intended recipient is prohibited. If this information is received in error, please contact the sender and destroy
the FAX immediately.