Vaccine Intake Forms

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Intake forms are necessary to ensure patients are healthy and able to have a vaccine. It will increase efficiency in the practice and improve the patients experience.
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Additional Details

Wilmer's intake forms can be used for the COVID vaccine (only) or for all other vaccinations. With multiple questions, it will help screen the health of the patient and obtain up-to-date information before seeing the doctor.

Available in small quantities (as low as 50) for pop up locations, rural areas or large quantities for an entire health group with multiple locations.

  • 8-1/2" x 14"
  • 1 part
  • 2 sided print
  • 50 per package (loose, chipboard and polywrapped for protection)


For a more customized form, imprint is available in the upper right hand corner for logos, doctor/facility name, phone number, and more. Custom forms, in example 1 sided print edge glued) can be quoted.

More Details

Intake Form Flyer