Caldwell Immunization Form
Please complete this form before arriving to your assigned vaccine appointment.

***๐€๐ฅ๐ฅ ๐ข๐ง๐Ÿ๐จ๐ซ๐ฆ๐š๐ญ๐ข๐จ๐ง ๐ฉ๐ซ๐จ๐ฏ๐ข๐๐ž๐ ๐ฐ๐ข๐ฅ๐ฅ ๐›๐ž ๐ค๐ž๐ฉ๐ญ ๐œ๐จ๐ง๐Ÿ๐ข๐๐ž๐ง๐ญ๐ข๐š๐ฅ. ๐–๐ž ๐ฐ๐ข๐ฅ๐ฅ ๐ง๐จ๐ญ ๐๐ข๐ฌ๐œ๐ฅ๐จ๐ฌ๐ž ๐ฒ๐จ๐ฎ๐ซ ๐ฉ๐ž๐ซ๐ฌ๐จ๐ง๐š๐ฅ ๐ข๐ง๐Ÿ๐จ๐ซ๐ฆ๐š๐ญ๐ข๐จ๐ง ๐ญ๐จ ๐š ๐ญ๐ก๐ข๐ซ๐ ๐ฉ๐š๐ซ๐ญ๐ฒ ๐ฐ๐ข๐ญ๐ก๐จ๐ฎ๐ญ ๐ฒ๐จ๐ฎ๐ซ ๐œ๐จ๐ง๐ฌ๐ž๐ง๐ญ ๐ฎ๐ง๐๐ž๐ซ ๐‡๐ˆ๐๐€๐€ ๐๐ซ๐ข๐ฏ๐š๐œ๐ฒ ๐‘๐ž๐ ๐ฎ๐ฅ๐š๐ญ๐ข๐จ๐ง๐ฌ.

๐‚๐š๐ฅ๐๐ฐ๐ž๐ฅ๐ฅ ๐๐ก๐š๐ซ๐ฆ๐š๐œ๐ฒ
804 South Falls Blvd Wynne, Arkansas 72396
Tel: 870-238-7085
Fax: 870-238-8937
Name (as it appears on insurance card) *
Date of Birth *
Gender *
Street Address *
City, State, Zip Code *
Phone Number *
Name of Family Doctor
Method of Payment *
Insurance Cardholder Name (if applicable)
Insurance Cardholder Date of Birth (if applicable)
COVID Screening: Do you have a fever of 100.4 ยฐF *
COVID Screening: What is your temperature? *
COVID Screening: Do you have a cough/shortness of breath/other COVID-19 symptoms (i.e. sore throat, new onset of muscle aches, lost the ability to taste or smell, etc.)? *
COVID Screening: Do you have or had pneumonia recently? *
COVID Screening: Have you returned from overseas travel or from states/metropolitan areas considered hot spots for COVID-19 spread in the last 14 days? *
COVID Screening: Have you had or had contact with anyone who has Novel Coronavirus (COVID-19) within the last 30 days? *
Are you sick today? *
Do you have allergies to medications, food, a vaccine component, or latex? *
Have you ever had a serious reaction after receiving a vaccination? *
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? *
Do you have cancer, leukemia, AIDS, or any other immune system problem? *
Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? *
Have you had a seizure or a brain or other nervous system problem? *
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? *
For women: Are you pregnant or is there a chance you could become pregnant during the next month? *
Have you received any vaccinations in the past 4 weeks? *
For those under 18 years old: Have you had a well-child visit with your pediatrician in the last 12 months? *
Have you had shingles in the last 6 months? *
Have you ever had a shingles vaccine before? *
Have you ever had a pneumonia vaccine before? *
If you've had a pneumonia vaccine, at what age?
Consent and waiver: I consent to the staff to administer the medication(s) mentioned below. I have reviewed the vaccine information sheet (s) and understand the benefits and risks of receiving this medication and choose to assume this risk. I fully release and discharge the standing order physician and the pharmacy, its affiliations and their officers, and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacyโ€™s privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy and will pay any copay or deductible that result. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any medications received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this medication. I agree to wait near the vaccination area for approximately 20 minutes to receive treatment in case of adverse reaction. *
Name of Vaccine:
Digital Signature of Patient or Guardian (Type Your Full Name) *
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