At Lone Star Pharmacy, we’re more than just your pharmacy. We’re your neighbors. We grew up in Santa Fe. Our kids go to the same schools, we eat at the

same restaurants, even shop at the same stores. We want our Santa Fe ISD teachers and students to have a happy, healthy, productive year!

YOUR SOURCE FOR HOMETOWN HEALTH

WE HEALTHY TEACHERS

4111 FM 1764, Suite F Santa Fe, Texas 77517Phone: (409) 925-9995 | Fax: (409) 925-9991

info@LoneStarPharm.com | LoneStarPharm.com

• Personalized Compounding • Prescription refills & transfers

• Immunizations, including flu • Friendly, hometown service

YOUR SOURCE FOR HOMETOWN HEALTH4111 FM 1764, Suite F Santa Fe, Texas 77517Phone: (409) 925-9995 | Fax: (409) 925-9991

info@LoneStarPharm.com | LoneStarPharm.com

2015 Flu Shots from Lone Star PharmacyDid you know you need a new flu shot every year to protect yourself against the viruses that are most likely to circulate each season? Flu season can begin as early as October and last as late as May. When more people get vaccinated against the flu, less flu can spread through our community. Our pharmacists and staff want all Santa Fe ISD teachers and students to have a happy, healthy and productive year. We are honored to be offering flu shots for you this year.

We’ll be visiting schools this October and doing on-site flu shots for Santa Fe ISD faculty and staff. All we need is a copy of your insurance card. The flu shot is covered in full by your insurance.

We want to be your pharmacy.At Lone Star Pharmacy, all teachers, military and police officers get a 5 percent discount on everything over the counter. We also offer free prescription delivery to Santa Fe ISD schools.

Prescription transfers are easy. Drop off an old prescription bottle at 4111 FM-1764, Suite F in Santa Fe or just call us at (409) 925-9995. We promise quick, friendly and professional service with a smile.

We’re here for you today, tomorrow, and always.We’re locally owned and operated, Santa Fe alumni and we truly care about our community. We’re a compounding pharmacy, so we can work with your doctor to create specialized medications. We offer online prescription refills, Flu Shots and immunizations, Pharmaceutical Grade Dietary Supplements, RX Skin Therapy Line, health, wellness and disease information and direct connection with your pharmacists.

Did you bring your immunization record card with you? yes no It is important for you to have a personal record of your vaccinations. If you don’t have a personal record, ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every time you seek medical care. Make sure your healthcare provider records all your vaccinations on it.

1. Are you sick today?

2. Do you have allergies to medications, food, a vaccine component, or latex?

3. Have you ever had a serious reaction after receiving a vaccination?

4. 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?

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?

6. In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?

7. Have you had a seizure or a brain or other nervous system problem?

8. During the past year, have you received a transfusion of blood or blood products,

or been given immune (gamma) globulin or an antiviral drug?

9. For women: Are you pregnant or is there a chance you could become pregnant

during the next month?

10. Have you received any vaccinations in the past 4 weeks?

Patient name: Date of birth: (mo.) (day) (yr.)

For patients: The following questions will help us determine which vaccines you may be given today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

NoYesDon’t Know

Screening Checklist for Contraindications to Vaccines for Adults

Form completed by: ___________________________________________ Date:_________________

Form reviewed by: ___________________________________________ Date:_________________

www.immunize.org/catg.d/p4065.pdf • Item #P4065 (1/15)

Technical content reviewed by the Centers for Disease Control and Prevention

Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org

4111 FM 1764, Suite F Santa Fe, Texas 77517 Phone: (409) 925-9995 Fax: (409) 925-9991 E-Mail: info@LoneStarPharm.com Web: LoneStarPharm.com

Contact Information

Last Name: First Name: Middle Initial:

Home Address: State: Zip:

Date of Birth: Sex:

Email: Would you like to receive email alerts?

Cell Phone: Would you like to receive text alerts?

Home Phone: Work Phone:

Patient Information Drug Allergies: __________________________________________________________________________________________________

Medical Conditions: __________________________________________________________________________________________________

Would you like to Auto Refill your prescriptions?

Do you need Easy Open Caps?

Who can pick up your medications?

We will need a copy of the front and back of your insurance card. We’ll also need a copy of your Texas Drivers License for some prescriptions. We appreciate your businesses – Lone Star Pharmacy Staff

Today’s Date: