2020 English Flu Vaccine Questionnaire

Is this vaccine for:

AdultChild (9 years old or older)
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

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

Yes - please fill in the information belowNo
Insurance Carrier:
Group ID#
Policy #
Do you have a history of severe allergic reactions to this vaccine?*

YesNo
Are you allergic to eggs or egg products and/or gelatin?*

YesNo
Do you have sensitivity to the preservative Thimerosal?*

YesNo
Have you ever had Guillen-Barre Syndrome?*

YesNo
Do you have an acute illness or fever today?*

YesNo
Have you ever had a severe reaction to latex?*

YesNo
Are you pregnant?*

YesNo
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 NameLast Name
Email
example@example.com
Date

MonthDayYear
Date
Should be Empty: