Influenza Vaccine Consent Form - (Smith's Drugs of Forest City)

If you have remaining questions, please call us at (828) 245-4591.

_____ Prescribe Wellness Billing outside of primecare:

_____ NCIR _____ Medicare part B

Paid (amt): ______ _____ other manual bill

Section I. Personal Information

Patient's Full Name: *

First Name Ml Last Name

Date of Birth: *

Age: *

Cell Phone Number: *

Email: *

Gender: *

Male Female

Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer

Address: *

Street Address Line 2

Mother's Maiden Name

First Name Last Name

Medical Conditions:

Primary Care Doctor: *

Doctor City/State: *

Section II. Questionnaire for Immunization

If you are 65 years old or older, you are eligible for the High-Dose vaccine. Please select which influenza vaccine

Senior (High dose or Adjuvanted) Flu Shot Normal Flu Shot

Please select the correct option below: *

	Yes	No	Don't know or N/A
ARE YOU SICK TODAY?
DO YOU HAVE ALLERGIES TO MEDICATIONS, FOOD, YEAST, EGGS, A VACCINE COMPONENT, LATEX OR ADHESIVES?
IF 65 YEARS OF AGE OR OLDER ONLY Are you allergic to neomycin, kanamycin, hydrocortisone, formaldehyde or CTAB?
Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
Do you have a long term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (example, diabetes), anemia or other blood disorder?
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
Have you been diagnosed with rhumatoid arthritis, ankylosing spondylitis or Chrohn's Disease?
In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, anti-cancer drugs, or have had radiation treatments?
have you had a seizure or a brain or other nervous system problem or Guillain Barre syndrome?
Do you have a history of faiinting, particularly with vaccines?
WOMEN ONLY: Are you pregnant or planning to become pregnant in the next 3 months?

Please specify the allergy from Q2:

Do you have Medicaid?

Yes No If yes, please call the pharmacy to schedule your appointment due to certain restrictions

Section III. Appointment Scheduler

UNDER 18 years old? We are not authorized to adminster a flu vaccine to patients with NORTH CAROLINA MEDICAID OR MEDICAID MANAGED CARE PLANS under the age of 18 years old. Please consult with your primary cary provider for flu shots if less than 18 years old.

Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later. If you miss an appointment, no doses will be held to guarantee your dose.**

Please pick a day and time for your vaccination *

Section IV. Signatures

I understand the benefits and risks of the influenza vaccine as described in the Vaccine Information Statement (VIS) ( https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html ), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo) *

Clear

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Signature of Acknowledgment of Notice of Privacy Practices: *

Clear

Please take or upload pictures of front & back of insurance card for billing purposes

Browse Files

Insurance authorization

I authorize the pharmacy to bill my insurance on my behalf for the immunization

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.