Skip to content

REFILL
PATIENTS
PHYSICIANS
PARTNERS

REFILL
PATIENTS
PHYSICIANS
PARTNERS

FILL/TRANSFER PRESCRIPTIONS

FIND THE CLOSEST PHARMACY LOCATION

REFER A PATIENT

PAY BILL ONLINE

FLU SHOT APPLICATION

Patients Form

Acceptance/Declination of the Influenza Vaccine
First Name*
Last Name*
Phone*
Email*
The CDC recommends that everyone over the age of 6 months get an annual influenza vaccination. I understand that I have been offered the vaccine, and if I decline to receive the vaccine, I am fully informed of the risks and benefits of the vaccination.
- I accept receipt of the influenza vaccination
- I refuse to take the annual flu shot
Patient Insurance Information for Influenza Vaccination
Patient Name*
Patient Date of Birth*
MM slash DD slash YYYY
Primary Insurance Name
Member ID/Cardholder ID/Medicare Number
Bin
PCN
Group
The following questions help us determine which vaccines you may be given today. If you answer “yes”, it does not necessarily mean you should not be vaccinated. If a question is not clear, please ask your pharmacist to explain it.
1. Are you sick today?*
- Yes
- No
- Don’t Know
2. Do you have allergies to medications, food (e.g. eggs), latex, or a vaccine component (e.g. gelatin, neomycin, polymyxin, yeast, thimerosal, etc.)?*
- Yes
- No
- Don’t Know
3. Have you ever had a serious reaction (including fainting) after receiving a vaccination?*
- Yes
- No
- Don’t Know
4. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?*
- Yes
- No
- Don’t Know
5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, or Crohn’s Disease?*
- Yes
- No
- Don’t Know
6. In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*
- Yes
- No
- Don’t Know
7. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?*
- Yes
- No
- Don’t Know
8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*
- Yes
- No
- Don’t Know
9. For women: are you pregnant or is there a chance you could become pregnant during the next month?*
- Yes
- No
- Don’t Know
10. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a physician's office or hospital?*
- Yes
- No
- Don’t Know
11. Have you received any vaccinations in the past 4 weeks?*
- Yes
- No
- Don’t Know
12. For the Td or Tdap vaccine: Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?*
- Yes
- No
- Don’t Know
If you are 65 years or older: Have you had the following vaccines?
Pneumococcal Vaccine
- Yes
- No
- Don’t Know
Zoster/Shingles Vaccine
- Yes
- No
- Don’t Know
I authorize the pharmacist to send copies of my vaccine documents to my primary care provider.
- Yes
- No
I acknowledge that the information here is true to the best of my knowledge, that I have read the Vaccination Information Sheet (VIS) provided, and that my vaccination record may be shared with my healthcare provider and federal or state agencies for registry reporting.

Contact Josefs Pharmacy

Josefs Pharmacy
Raleigh, North Carolina
919.212.2555 | Phone
919-849-8923 | Text Only

Josefs Pharmacy
Durham, North Carolina
919.680.1540 | Phone
919-750-0635 | Text Only

All About Josefs

About Josefs
Specialty Accreditations
Specializations
Join Josefs Team
News
Homepage

About Josefs
Specialty Accreditations
Specializations
Join Josefs Team
News
Homepage

Sign up for Services

Refer A Patient & Rx Forms
MedPacks (Blister Pack or Pouch Packaging)
Flu Shots & Immunizations
Schedule Online Pharmacist Consultation
Specialty Pharmacy Rx Forms & Services
Long Term Care Services (ALF & SNF)
Free Savings Reviews
Extended Rx Supply Options

Refer A Patient & Rx Forms
MedPacks (Blister Pack or Pouch Packaging)
Flu Shots & Immunizations
Schedule Online Pharmacist Consultation
Specialty Pharmacy Rx Forms & Services
Long Term Care Services (ALF & SNF)
Free Savings Reviews
Extended Rx Supply Options

Prescriptions Support & Help

Find the Closest Pharmacy
Fill or Transfer Your Prescription
Refill Your Prescription (Rx)
Make A Payment
Advocacy & Memberships
FAQs, Forms & Education
Download App
Privacy Policy
Complaints/Issues

Find the Closest Pharmacy
Fill or Transfer Your Prescription
Refill Your Prescription (Rx)
Make A Payment
Advocacy & Memberships
FAQs, Forms & Education
Download App
Privacy Policy
Complaints/Issues

© 2022 Josefs Pharmacy | Privacy Policy

Facebook Twitter Youtube Linkedin Android Apple

SIGN UP FOR OUR NEWS LETTERS

FILL/TRANSFER PRESCRIPTIONS

FIND THE CLOSEST PHARMACY LOCATION

REFER A PATIENT

PAY BILL ONLINE

Call 919-212-2555

FILL/TRANSFER PRESCRIPTIONS

FIND THE CLOSEST PHARMACY LOCATION

REFER A PATIENT

Receive the latest news

Subscribe To Our Monthly Newsletter

Get notified about latest news, promotions and events.

Email Address