Independent Rx LTC Influenza (Flu) Vaccine Consent Form

Name (as it appears on your insurance card)*

First Name Middle Name Last Name

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Gender*

Name of Facility

Type in the name of your facility, if applicable.

Medicare ID number

If you know your Medicare ID number, please insert it here.

Upload Medicare ID

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If you have a photo of your Medicare ID you can upload it here.

Chronic Diseases (please list if any)

Drug Allergies (please list if any)

Primary Care Physician (First and Last name)

Please answer the following questions.

Have you ever received the influenza vaccine before? If yes, when?*

Yes or No. If Yes, when?

Do you have an allergy to eggs, any other vaccines, or vaccine components*

YesNo

Do you have a latex allergy?*

YesNo

Are you pregnant, if applicable?

YesNo

Do you have an illness or fever?*

YesNo

Do you have a history of Guillain-Barré syndrome?*

YesNo

For Medicare Recipients: I authorize the release of any medical or other information necessary to process this claim, I also request payment of government benefits either to myself or to the party who accepts assignment.

I have read or have had explained to me the information in the Vaccine Information Statement about the vaccine, and I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine and ask that the vaccine be given to me or the person named below for whom I am authorized to make this request.*

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