Flu Vaccine Questionnaire - Rogersville Pharmacy MO

Patient Name

Patient Date of Birth

Email

Address

City

State

Zip Code

Phone Number

Primary Physician Name

Do You have Insurance?

Insurance Card

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If you have insurance please provide and image of your Insurance card.

1. Is the person to be vaccinated sick today?

2. Does the person to be vaccinated have an allergy to an ingredient of the vaccine?

3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?

4. Has the person to be vaccinated ever had Guillain Barré Syndrome?

5. Has the person to be vaccinated ever felt dizzy or faint before, during, or after a shot?

6. Is the person to be vaccinated anxious about getting a shot today?

7. I consent to receiving an influenza vaccine today.

Please type your first and last name

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Rogersville Pharmacy MO

Established in 2007, Rogersville Pharmacy offers personalized service and competitive pricing. Locally owned and operated, we care about you and your family.

Find us

317 S Main Street, Rogersville, Missouri 65742, United States

Contact us

jim@momandpopdrug.com

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