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Friday Harbor Drug
210 Spring St
Friday Harbor, WA 98250
360-378-4421
contact@fridayharbordrug.com
Vaccine Administration Record
Name
*
First Name
Last Name
Date of Birth:
*
MM
DD
YYYY
Race
*
...
Caucasian
African American
Hispanic
Asian
American Indian
Pacific Islander
Other
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Mobile
Home
Work
Email
Primary Care Provider:
Medicare Number (if applicable):
The following questions will help determine which vaccine may be given in the pharmacy. Please answer these questions for the person receiving the vaccine today. If the questions is not clear, please ask the pharmacist to explain it.
1) Have you ever received a vaccine?
*
...
Yes
No
Not Sure
2) Are you sick today?
*
...
Yes
No
Not Sure
3) Do you have any allergies to medications, eggs, gelatin, thimerosal, any vaccine, or any vaccine component?
*
...
Yes
No
Not Sure
If yes, what are your allergies and what reaction does that cause?
4) Have you ever had a serious reaction after a vaccination?
*
...
Yes
No
Not Sure
If yes, what reaction did you have?
5) Have you ever had a Guillain-Barre syndrome?
*
...
Yes
No
Not Sure
6) Do you have a chronic illnesses (including cancer, leukemia, AIDS/HIV, and other immune system conditions)?
*
...
Yes
No
Not Sure
If yes, please list your chronic illnesses.
For women: Is it possible that you are pregnant or may become pregnant in the next three months?
...
Yes
No
Not Sure
I have read, or have had explained to me, information about the vaccines I am to be given, and the diseases the vaccines are intended to mitigate. I believe I understand the benefits and risks of the vaccine to be given. I authorize the vaccine to be given to me or to the person named above, for whom I am authorized to make this request.
Electronic Signature of Person Receiving Vaccine, or Guardian of Person Receiving Vaccine
*
Date:
*
MM
DD
YYYY
For Pharmacy Use Only
Vaccine Given:
Date Administered:
Manufacturer:
Lot Number:
Expiration Date:
Injection Site:
Signature of vaccine Administrator:
Thank you!
