Get South Carolina Injectable Influenza Screening Questionnaire And Consent Form

Filling out the South Carolina Injectable Influenza Screening Questionnaire And Consent Form online is a straightforward process. This guide will provide you with detailed, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out your form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin the form by entering your Medicare number, if applicable. If you are using cash or insurance, specify the insurance carrier name, group number, and ID number.
3. Complete the patient information section, including your name, date of birth, age, phone number, address, city, state, and zip code.
4. Indicate your gender by selecting either 'M' or 'F' and specify which vaccine(s) you would like to receive.
5. If applicable, fill out any relevant medical conditions and enter your weight if it is less than 110 lbs.
6. List your primary doctor's name and phone number, along with any alternate doctor information.
7. Provide your email address, noting that by doing so, you consent to receive email communications from Rite Aid.
8. Answer the screening questions regarding your health and vaccination history by selecting ‘Yes’, ‘No’, or ‘Don’t Know’ for each question.
9. Review the consent section to understand the implications of your vaccination consent; ensure all acknowledgments are read and understood.
10. Sign and date the form at the bottom. If you are under 18, a parent or legal guardian must sign.
11. Once all fields are filled in, save your changes, and choose to download, print, or share the complete form as needed.

Complete your forms online today to ensure a smooth vaccination experience.