2020 English Flu Vaccine Questionnaire

Name *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Do you have medical insurance? *

Yes - please fill in the information below No
Insurance Carrier:
Group ID#
Policy #
Do you have a history of severe allergic reactions to this vaccine? *

Yes No
Are you allergic to eggs or egg products and/or gelatin? *

Yes No
Do you have sensitivity to the preservative Thimerosal? *

Yes No
Have you ever had Guillen-Barre Syndrome? *

Yes No
Do you have an acute illness or fever today? *

Yes No
Have you ever had a severe reaction to latex? *

Yes No
Are you pregnant? *

Yes No
I have received, read and understand the vaccine information sheet and understand the risk and benefits of the vaccine. I authorize the vaccine to be given to me or the person above, for whom I am authorized to sign, and I authorize Neighborhood Healthsource to bill my insurance for this vaccine.
Signature

Clear
Printed name of adult person signing

First Name Last Name
Email
example@example.com
Date

Month Day Year
Date
Should be Empty: