Patients Form

  • Acceptance/Declination of the Influenza Vaccine

  • Patient Insurance Information for Influenza Vaccination

  • Date Format: MM slash DD slash YYYY
  • 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.
  • If you are 65 years or older: Have you had the following vaccines?
    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.