Rite Aid Flu Shot PDF Details

This Rite Aid form includes sections for the patient to indicate their consent to receive the vaccination and acknowledge various privacy practices and vaccination information sheets. Patients are asked about their medical history, allergies, previous vaccinations, and other relevant information to ensure they receive the appropriate vaccines and doses. The form is also used to authorize the release of medical information and request payment from insurance providers or third-party payers, as needed. Lastly, it has a section for pharmacy staff to record the lot numbers, expiration dates, and administration site for each vaccine, as well as their signatures and license information.

QuestionAnswer
Form NameRite Aid Flu Shot Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesflu vaccine paperwork, get the rite aid application form for flu shot, flu shot forms, information influenza questionnaire consent

Form Preview Example

Insurance Card: ________________ ID: ___________________ Group: ______________

I do not have insurance

Identification must be provided for COVID Vaccine

 

Driver's License State___ #__________ State ID State___ #______________

I do not have ID

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?___________________________________________

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)

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.

Yes

No

Don’t Know

If a question is not clear, please ask your pharmacist to explain it.

 

 

 

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

 

 

 

 

 

 

 

12-2020

I authorize 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 cover 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

o

Place RX Label Here

o

Place RX Label Here

Influenza Injectable

o

DTaP

Influenza Injectable

o

DTaP

o

Pneumococcal

o

Zoster (Shingles)

o

Pneumococcal

o

Zoster (Shingles)

o

Hepatitis B

o

Tdap

o

Hepatitis B

o

Tdap

o

HPV

o Hepatitis A & B

o

HPV

o Hepatitis A & B

o

Varicella

o

Other:

o

Varicella

o

Other:

o

IPV:

 

 

o

IPV:

 

 

o

Meningococcal

 

 

o

Meningococcal

 

 

o

Td

 

 

o

Td

 

 

o

Hepatitis A

 

 

o

Hepatitis A

 

 

o

MMR

 

 

o

MMR

 

 

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): ________________________________________

How to Edit Rite Aid Flu Shot Form Online for Free

Creating forms together with our PDF editor is more straightforward when compared with anything. To enhance flu vaccine paperwork the file, you'll find nothing you will do - basically stick to the actions below:

Step 1: Hit the button "Get form here" to open it.

Step 2: You're now on the document editing page. You can edit, add information, highlight particular words or phrases, insert crosses or checks, and add images.

The following parts will compose the PDF document that you will be filling in:

completing flu vaccine consent form pdf step 1

Provide the appropriate data in The following questions will help, Yes No Dont Know, Are you sick today, Do you have a long term health, Do you have a long term health, Do you have allergies to, Have you received any vaccinations, Have you ever had a serious, Do you have a neurological, Do you have cancer leukemia AIDS, and During the past year have you field.

Completing flu vaccine consent form pdf part 2

You'll have to write particular details inside the section During the past year have you, For women Are you pregnant or, Did you bring your Immunization, Are you currently enrolled in one, Have you had the following vaccines, Yes No Dont Know, Pneumococcal Vaccine you may need, Shingles Vaccine, and Whooping Cough Tdap Vaccine.

flu vaccine consent form pdf During the past year have you, For women Are you pregnant or, Did you bring your Immunization, Are you currently enrolled in one, Have you had the following vaccines, Yes No Dont Know, Pneumococcal Vaccine you may need, Shingles Vaccine, and Whooping Cough Tdap Vaccine fields to fill

The I acknowledge that if my insurance, Patient Signature or legal, If legal guardian print name, PHARMACY USE ONLY, Place RX Label Here, Place RX Label Here, Zoster Shingles Tdap, o DTaP o o o Hepatitis A B o Other, Influenza Injectable Pneumococcal, Varicella IPV, o o o Hepatitis B o HPV o o o, Zoster Shingles Tdap, o DTaP o o o Hepatitis A B o Other, Influenza Injectable Pneumococcal, and Varicella IPV section can be used to indicate the rights and responsibilities of both sides.

stage 4 to entering details in flu vaccine consent form pdf

Finish by reviewing the next fields and completing the appropriate particulars: Clinic Yes No, Signature of pharmacist who, License NPI Date, and Signature of Certified Immunizing.

part 5 to completing flu vaccine consent form pdf

Step 3: If you're done, click the "Done" button to export the PDF file.

Step 4: It could be easier to prepare copies of the file. You can rest easy that we are not going to reveal or read your particulars.

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