Vaccine Clinic Prescreening - Yorkville Pharmacy

General Info

Name *

DL Number

Street Address *

City *

State *

Zip *

Phone *

Date of Birth *

Gender *

Ethnicity *

Race *

Primary Physician

Medicare Number (Part B)

Do you have insurance other than Medicare?

If so, Insurance Carrier and ID

Make sure to bring a copy of your insurance card to your appointment.

Emergency Contact - Name *

Emergency Contact - Relation *

Emergency Contact - Phone *

Administration Site for Vaccine *

Left/Right Deltoid is the most common choice.

Release of Information / Assignment of Insurance Benefits

I believe I understand the benefits and risks of the vaccine I have selected and ask that the vaccine be given to me or to the person named above for whom I am authorized to make this request. Under HIPAA provisions, I authorize the release of information about my immunization status and health status for continuing health services only which may include my referring physician or other health care agencies assigned to my care. All health information provided is held in strict confidence, following HIPAA regulations. I acknowledge receipt of Notice of Privacy Practices from Yorkville Pharmacy. Medicare or 3rd party patients: I do herby authorize Yorkville Pharmacy to release information and request payment for immunization services. I certify that the information given by me in applying for payment under Medicare or any 3rd party is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf. Should any information provided prove incorrect, thus denying payment, I personally guarantee payment for services rendered on my behalf and may be billed accordingly.

Signature

Reset Signature

Date *

Immunization Screening

Have you ever had a reaction to any vaccine? *

Please describe:

Do you have any drug or food allergies? *

Please describe:

(How are you today?) Are you experiencing substantial fever, diarrhea, or vomiting today? *

Please describe:

Are you being treated by a doctor for a disease? *

Please describe:

Which medications do you take? *

Do you have any form of cancer, leukemia, or immune system problem (for example, taking cortisone, prednisone or other steroids, anticancer drugs, or x-ray treatments)? *

Please describe:

Have you received a transfusion of blood or plasma or any medicine containing antibodies (immune or gamma globulin) in the past year? *

Please describe:

For women: Are you pregnant or is there a chance you could become pregnant in the next 3 months?

Do you smoke cigarettes? *

Did you quit smoking recently?

Do you breathe in a lot of other people's smoke? *

Did you bring your immunization record card with you? *

It is important to have a personal record of your shots. If you don't have a record card, ask your health care provider to give you one. Bring this record with you to every health care visit. Make sure your health care provider records all of your vaccinations on it.

I agree to be vaccinated today. I have received and understand information about the vaccine or vaccines I will receive. I have had my questions answered to my satisfaction. I authorize the provider performing this service to release to and access from my insurer (if applicable) and primary health care provider any medical or other information necessary. I authorize the payment of medical benefits to the provider performing this service.

Patient's Name *

Date *

Captcha *

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