Clinic Yes 2026

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108 votes

The document is a Screening Questionnaire and Consent Form for patients receiving vaccinations at a pharmacy. It collects patient information, medical history, and consent for vaccine administration, while also addressing potential allergies and health conditions. The form includes sections for patient authorization regarding the sharing of vaccination records and acknowledges the importance of consulting a primary care physician.

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Click ‘Get Form’ to open the Clinic Yes document in the editor.
Begin by entering your Insurance Card number, ID, and Group information at the top of the form.
In the Patient Information section, fill in your name, date of birth, age, phone number, address, city, state, zip code, and gender. Ensure all fields marked with an asterisk (*) are completed.
Indicate which vaccine(s) you would like to receive today and list any medical conditions you may have. If your weight is less than 110 lbs., please enter it in the designated field.
Answer the screening questions by selecting 'Yes', 'No', or 'Don’t Know' for each item. If any question is unclear, feel free to ask your pharmacist for clarification.
Review the authorization statements at the end of the form and select 'Yes' or 'No' as applicable before signing. If you are a legal guardian, ensure to print your name as well.

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