Fillable Screening Questionnaire and Consent Form (Caesar Rodney School District)

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Screening Questionnaire and Consent Form (Caesar Rodney School District)

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The Screening Questionnaire and Consent Form (Caesar Rodney School District) form is 2 pages long and contains:

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  • 15 check-boxes
  • 77 other fields

Country of origin: US
File type: PDF

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Insurance Card: ________________ ID: ___________________ Group: ______________ I do not have insurance
12-2020
Screening Questionnaire and Consent Form
Patient Information: (Patient to complete)
Patient Name: ____________________________Date of Birth: _________ Age: _____ Phone#: ___________________
Address: ________________________________ City: ___________________________ State: ____ Zip: ____________
Email Address:_____________________________________________________________________________________
Gender: M or F Which vaccine(s) would you like to receive today?___________________________________________
Medical Conditions: ___________________________________________ Enter Weight if less than 110 lbs.: __________
**FOR EMERGENCY USE ONLY**
Primary Care Physician (PCP): _________________________________ Dr. Phone: _____________________________
PCP address- City ________________________________________ State______Zip Code _______________________
I authorize the pharmacist to send copies of my vaccine documents to my primary care provider. Yes � No �
Failure to select one of these boxes will result in the vaccine documents being sent to my primary care provider, if known, as state laws & regulations
require for my state.
The following questions will help us determine which vaccines may be given today.
If a question is not clear, please ask your pharmacist to explain it.
Yes No Don’t Know
Are you sick today?
Do you have a long term health problem with heart disease, kidney disease,
metabolic disorder (e.g. diabetes), anemia or other blood disorders?
Do you have a long term health problem with lung disease or asthma? Do you smoke?
Do you have allergies to medications, food (i.e. eggs), latex or any vaccine component
(e.g. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin,
gelatin, baker’s yeast or yeast)?
Have you received any vaccinations in the past 4 weeks?
Have you ever had a serious reaction after receiving a vaccination?
Do you have a neurological disorder such as seizures or other disorders that affect the
brain or have had a disorder that resulted from a vaccine (e.g. Guillain-Barre Syndrome)?
Do you have cancer, leukemia, AIDS, or any other immune system problem?
(in some circumstances you may be referred to your physician)
Do you take prednisone, other steroids, or anticancer drugs, or have you
had radiation treatments?
During the past year, have you received a transfusion of blood or blood products,
including antibodies?
Are you a parent, family member, or caregiver to a new born infant?
For women: Are you pregnant or could you become pregnant in the next three months?
Did you bring your Immunization Record Card with you?
Are you currently enrolled in one of our medication adherence programs at Rite Aid
(OneTrip Refill, Automated Courtesy Refills, or Rx Messaging- Text, Email, Phone)?
Have you had the following vaccines: Yes No Don’t Know
• Pneumococcal Vaccine-- *you may need two different pneumococcal shots*
• Shingles Vaccine
• Whooping Cough (Tdap) Vaccine
Identification must be provided for COVID Vaccine
Driver's License State___ #__________ State ID State___ #______________
I do not have ID
Ethnicity: Hispanic or Latino(1) Not Hispanic or Latino(2) Unknown(3)
Race: American Indian/Alaska Native(4) Asian(3) Native Hawaiian/Other Pacific Islander(5)
Black or African American(1) White(2) Unknown(6)
I autho
rize the release of any medical or other information with respect to this vaccine to my healthcare providers,
Medicare, Medicaid or other third party payer as needed and request payment of authorized benefits to be made on my
behalf to Rite Aid.
- I acknowledge that if my insurance does not cov
er the cost of administering the vaccine at the pharmacy, then
payment must be made at the time of the administration of the vaccine.
- I acknowledge that my vaccination record may be shared with federal or state or city agencies for registry reporting.
- I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area, for 15
minutes, after the administration of the immunization.
- I acknowledge receipt of Rite Aid’s Notice of Privacy Practices for Protected Health Information.
- I acknowledge that the administration of an immunization or vaccine does not substitute for an annual check-up with
the patient’s primary care physician.
- For CA: I acknowledge that Rite-Aid intends to share my vaccination record with the California Immunization Registry
(CAIR) and that I have reviewed the ‘CAIR Immunization Notice to Patients and Parents’ attached to this form.
- For CA: I acknowledge that if I do not want my immunization information shared with other CAIR users, I must
complete and submit to CAIR a “Decline or Start Sharing/Information Request Form” obtained either from the
pharmacy or downloaded from the CAIR website (http://cairweb.org/cair-forms/).
- I certify my receipt of the services covered by this claim. I request that payment be made on my behalf. I authorize the
holder to release medical information about me to any party involved in payment or their agents.
- I have read, or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had the
opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the
vaccine(s). I consent to, or give consent for, the administration of the vaccine(s). I fully release and discharge Rite
Aid Corporation, its affiliates, officers, directors, and employees from any liability for illness, injury, loss, or damage
which may result there from.
Patient Signature or legal guardian signature __________________________________________________________
If legal guardian print name _________________________________________________________________________
PHARMACY USE ONLY
Lot #_
_____________________________ Lot #_______________________________
Exp. Date _________________________ Exp. Date___________________________
Site RA or LA- Circle One Site RA or LA- Circle One
Clinic – Yes No
Signature of pharmacist who administered Vaccine(s) and provided VIS to patient: __________________________________________
License #: ____________ NPI #: ______________ Date: _________
Signature of Certified Immunizing Technician or Intern who administered Vaccine(s): ________________________________________
Place RX Label Here
Place RX Label Here
o Influenza Injectable
o Pneumococcal
o Hepatitis B
o HPV
o Varicella
o IPV:
o Meningococcal
o Td
o Hepatitis A
o MMR
o DTaP
o Zoster (Shingles)
o Tdap
o Hepatitis A & B
o Other:
o Influenza Injectable
o Pneumococcal
o Hepatitis B
o HPV
o Varicella
o IPV:
o Meningococcal
o Td
o Hepatitis A
o MMR
o DTaP
o Zoster (Shingles)
o Tdap
o Hepatitis A & B
o Other:
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Insurance Information required at time of COVID
Immunization Administration
For some insurance plans this will be processed by your prescription plan, for others it will be
covered by your medical plan. Both will be collected at this time to ensure accurate process
completion.
Your Name: First _______________ Last ____________________
Date of Birth __________________ Last 4 digits of SSN _____________
If over 65 or on Medicare your Medicare part A/B # ________________
Prescription Plan information:
Name of Plan _________________________________________
Bin # ________________________________________________
PCN # ________________________________________________
Group # ______________________________________________
ID # __________________________________________________
Relationship circle one: Primary Spouse Child
If not Primary, please provide primary insured’s name: ______________
Medical Plan information:
Name of Plan _________________________________________
Group # _____________________________________________
ID # _________________________________________________
Processor control # if on card _____________________________
Relationship circle one: Primary Spouse Child
If not Primary, please provide primary insured’s name: ______________
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Screening Questionnaire and Consent Form (Caesar Rodney School District)

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Completed 15 June 2021

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