Days (if known)

Select all that apply

Select all that apply

Do you have any allergies?

Have you had a serious allergic reaction to a vaccine or medication given by injection?

Are you pregnant or possibly pregnant?

Do you have any allergies?

Have you had a serious allergic reaction to a vaccine or medication given by injection? (female)

Have you received all your routine immunizations?

Approximate date of last flu vaccine

Approximate date of last tetanus vaccine

Hepatitis A

Hepatitis B

Typhoid

Dukoral

HPV

Please specify any other travel vaccines you may have received (optional)

Do you currently have any medical conditions?

Are you currently taking any over-the-counter or prescription medications?

I confirm that all the information provided is accurate and complete to the best of my knowledge. While this registration does not guarantee a prescription treatment, a pharmacist will review my information and determine if it is appropriate to prescribe a treatment or if a referral is necessary.

I give my consent to receive pharmacist services, which may include an assessment and treatment related to the requested or recommended service. This includes the initiation of medication therapy, as well as any necessary assessments or referrals, as deemed necessary by the pharmacist, in accordance with applicable laws and regulations. I understand that personal health information may be collected, used, and disclosed by my pharmacy as necessary for the purposes of providing these services. This may include sharing my information with other healthcare providers as needed for continuity of care.