Shingrix Intake/Screening

Name*

First NameMiddle NameLast Name

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Date of Birth*

Date

Gender at Birth*

Race*

Ethnicity*

The following questions will help us determine if there is any reason we should not give you the shingle shot 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.

YesNo

Please indicate if you are allergic to any of the following:*

Rows	YES	NO	UNSURE
Medications
Food
Vaccine component
Latex

If you answered yes to any of the allergy questions above, please list your allergies and the reaction

YesNo

Which vaccine did you previously react to and what was the reaction:

YesNoUnsure

If yes, please list your vaccinations here:

YesNo

When did you get your first dose of Shingrix?

Date

A vaccine, like any medication, is capable of causing serious problems such as severe allergic reactions, The risk of any vaccine causing serious harm, or death is extremely small. The most common side effects may include local symptoms like slight tenderness, redness, itching, or swelling at the injection site. Systemic symptoms are usually less common but may include fever, malaise, and muscle pain. Immediate presumable allergic reactions such as hives, angioedema, allergic asthma, or systemic anaphylaxis occur rarely after immunization. You will be monitored for immediate reactions following your immunization. Signs of an allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, or a fast heartbeat within a few minutes to a few hours following your immunization. If after you are allowed to leave the immunization area you develop a high fever, behavior changes, flu-like symptoms you should see your doctor right away. *

Rows	Check each box
I have read or had read to me the information regarding the shingles vaccine. I have received a copy of the Vaccine Information Sheet (VIS) for the vaccine being administered to me today (if you provided your email address this will be emailed to you or you may click this link at the end of the form to view online).
I had the opportunity to ask questions and if I asked any questions they were answered to my satisfaction. I understand the benefits and risks of the vaccine that is going to be administered to me. I further understand that while this vaccine may reduce my risk for contracting shingles, it is not guaranteed that I will not get the shingles.
I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from my receipt of the immunization administered.
I request this vaccine be administered to me during my scheduled appointment. I am releasing Inman Pharmacy, INC as well as its agents and employees from any and all claims arising out of, in connection with, or in any way related to my receipt of this immunization. Neither the pharmacy nor its agents or employees shall, at any time or to any extent whatsoever, be liable, responsible nor in any way accountable for any loss, injury, death, or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccine described above.
Massachusetts law (M.G.L.c 111, Section 24M) requires providers to report immunization information to a computerized immunization registry known as the Massachusetts Immunization Information System (MIIS). The MIIS stores immunization records for you and your healthcare provider and can help prevent outbreaks of disease like measles and the flu. All information in the MIIS is kept secure and confidential. The MIIS allows information to be shared with health care providers, school nurses, local boards of health, and stat agencies concerned with immunization. You have the right to object to the sharing of your immunization information across providers in the MIIS. If you wish to do so you will need to ask for an objection form. For more information you can visit the MIIS website at www.mass.gov/dph/miis or contact the Massachusetts Immunization Program directly at (617) 983-6800 or 888-658-2850.

Vaccine Information Sheet Shingrix

I have insurance. By choosing this option I am authorizing Inman Pharmacy, INC to bill my pharmacy insurance to cover the vaccine and administration cost. I have uploaded a copy of my pharmacy benefit card. I understand the pharmacy may contact me to obtain additional information if necessary.I do not have insurance. I plan to pay out of pocket for this vaccine.

MIIS Information Sheet

File Upload

Signature of Person to Receive Vaccine and EUA/VIS*

Date Signed*

Date

Shingrix Intake/Screening

Shingles Screening Questions

Consent

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