Read Flu_Registration_Form.pdf text version

GUEST INFORMATION Last Name: First Name: Date of Birth: Gender:

Male

Contact Information: Street Address:

/

/

Female

(mm/dd/yyyy)

City: State: Home Phone: Mobile Phone: ( ( Zip Code: ) ) -

Primary Care Physician (PCP) Name: Phone: Address:

Currently don't have a PCP or don't know contact information

Previous Shots: Have you ever fainted or felt dizzy when receiving a shot?

Yes No

I want to be protected from: Flu Whooping cough Tetanus/Diphtheria Pneumonia Shingles Meningitis

SCREENING QUESTIONS

GENERAL ­ ANSWER FOR ALL IMMUNIZATIONS 1. 2. 3. 4. 5. 6. 7.

GENERAL ­ ANSWER FOR ALL IMMUNIZATIONS

Age: Are you pregnant? Yes No No

(not a contraindication for all vaccines, RPh see reverse) (not a contraindication for all vaccines, RPh see reverse)

Are you allergic to thimerosal? Yes

Are you currently sick with a moderate to high fever? Yes

No No No

Do you have a bleeding disorder that makes you prone to bleeding? Yes If you use blood thinners, has your dose changed in the last 2 weeks? Yes Guillain-Barre after receiving a vaccine? Yes No Yes No

Do you have an active brain/nerve disorder or have you developed a brain/nerve disorder such as Have you had a serious reaction after receiving a vaccination?

8.

If "Yes", name of vaccine? ______________________________ (not a contraindication for all vaccines, RPh screen appropriately)

FLU (INACTIVATED INFLUENZA) FLU (INACTIVATED INFLUENZA)

1. 2.

Are you allergic to eggs or egg products? Yes If under 9 years old:

No Yes No two shots one shot

Is this the first-ever flu vaccination he/she received? If last year was the first-ever flu vaccination, was it given as:

(Two flu doses separated by 1 month are recommended for first-time vaccination when under 9 years old)

TETANUS (Td) AND WHOOPING COUGH (Tdap) (TETANUS/DIPHTHERIA AND TETANUS/DIPHTHERIA/PERTUSSIS) TETANUS (Td) AND WHOOPING COUGH (Tdap) (TETANUS/DIPHTHERIA AND TETANUS/DIPHTHERIA/PERTUSSIS)

1.

Have you experienced a coma or multiple seizures within 7 days after receiving a dose of Tetanus/Diphtheria or Tetanus/Diphtheria/Pertussis vaccine? Yes No

SHINGLES (ZOSTER) SHINGLES (ZOSTER)

1.

Do you have an impaired immune system? Yes

No

(Meningococcal and Pneumococcal immunizations have no additional questions)

Unless otherwise noted, guests who answer "Yes" to any question are not eligible to receive the vaccine. Refer guest to their Primary Care Provider. © 2012 Target Brands, Inc. Target and the Bullseye Design are registered trademarks of Target Brands, Inc. RX8731 (6/12)

Privacy Policy

I acknowledge that I have received the Target Pharmacy® Notice of Privacy Policy.

Agreement to Pay

I request that my health plan, insurance company, Medicare or Medicaid, as applicable, make payment for services I receive at Target Pharmacy directly to Target. I understand that I am responsible for payment for any services that are not covered by any health plan, insurance company, Medicare or Medicaid, including co-payments and deductibles. I will be billed for the services provided and I will be responsible for payment. Medicare Part B beneficiaries who receive services at Target Pharmacy will receive a Medicare Summary Notice (MSN) from Trailblazer Health Enterprises. 1. I have read (or have had explained to me) the Vaccine Information Statement for the vaccine(s) I will receive today. I have had a chance to ask questions. All of my questions have been answered to my satisfaction. I understand the benefits and risks of the vaccine(s) and request that the vaccine(s) be given to me or my dependent. 2. I hereby hold harmless Target Corporation, and any supervising physicians, employees, and affiliates of these organizations, from all responsibility for action that may occur as a result of the vaccination. This release shall be binding upon my heirs, assigns, executors, administrators, and personal representatives.

By signing below, I am confirming that I understand and consent to the assignment of benefits, payment responsibility, treatment(s), and disclosures above.

Guest Name: Signature:

Date:

If signed by anyone other than the patient, mark the box that describes relationship to patient: Parent Guardian Health care agent

Name of Vaccine: Manufacturer:

CDC Recommended Age 11yo and older 7yo and older 19yo and older 2-55 years old 3yo and older 3yo and older 18-64 years 65yo and older 50yo and older Thimerosal No YES No No YES No* No No No

Other:

Lot Number: Expiration Date:

OK if Pregnant After 2nd trimester No No No No YES* YES No No (Fluvirin* has <1mcg thimerosal)

Pharmacist Use Only

Complete BEFORE vaccine administration

Indicate Dose Dose: 0.5mL 0.5mL 0.5mL 0.5mL 0.5mL Prefilled Prefilled Prefilled 0.65mL Vaccine Tdap Td Pneumococcal Meningococcal Influenza Multi-dose vial Influenza Intramuscular Influenza Intradermal Influenza High Dose Zoster

Did guest provide Primary Care Physician information? Did you verify vaccine can be given in your state and that guest meets state age requirements? Did guest indicate a history of fainting or dizziness when having a shot? If under 9y.o., will a second dose be needed?

If this is the second dose, date 1st dose was received:

Yes Yes Yes Yes

No No No No

Process details at: Workbench | Pharmacy | Vaccines | Workflow

Guest received VIS: Inactivated Influenza | Tdap/Td | Pneumococcal | Meningococcal | Zoster | Edition date:

Complete AFTER vaccine administration

Injection Site: Intramuscular Intradermal Subcutaneous R Deltoid R Deltoid

Date of Administration:

L Deltoid L Deltoid L posterolateral arm 1" needle (most guests); 5/8" (<130lbs); 5/8" needle Zoster Only 1 ½" (M>260; F>200) (pre-filled intradermal influenza only)

R posterolateral arm

Did guest experience an adverse reaction from the vaccine? Yes Did you recommend the guest receive care from another physician? Yes Did you contact emergency medical personnel for the guest? Yes

No No No

All anaphylactic reactions and other reactions as identified by the CDC must be reported to VAERS. Go to http://vaers.hhs.gov/esub/index# and complete the form as directed. Make a copy of the form and forward to your Oversight Physician and RxBP. Please reference http://vaers.hhs.gov/professionals/index for a CDC listing of reportable events.

RPh Name & Title: RPh Signature:

PLACE RX BACK TAG LABEL HERE

RETAIN SEQUENTIALLY WITH RX HARD COPIES

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