Insurance Card: ________________ ID: ___________________ Group: ______________ I do not have insurance
Screening Questionnaire and Consent Form
Patient Information: (Patient to complete)
Patient Name: ____________________________Date of Birth: _________ Age: _____ Phone#: ___________________
Address: ________________________________ City: ___________________________ State: ____ Zip: ____________
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,
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)