Influenza Questionnaire and Consent Form
The information you provide in this form is secure on a HIPAA-compliant platform. If you do not have an email or would prefer to give information over the phone, please call the pharmacy at 270-885-5515.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Email
*
example@example.com
Phone
*
Gender
*
Male
Female
Address
*
Address
Street Address Line 2
City/State
State / Province
Zip Code
Insurance Information
Please select type of insurance
*
Medicaid
Medicare Part B
Private Insurance
No Insurance
*
If providing insurance information, I give consent that Save More Drugs, Dr. Laura Purdy, and affiliates may bill my medical insurance for the service provided.
Medicaid Provider
*
Policy/Member ID #
*
Medicaid #
*
Group #
*
Subscriber ID #
*
Responsible Party
*
Policy Holder's Date of Birth
*
/
Month
/
Day
Year
Date
Insurer
*
Member ID
*
Bin #
*
PCN
*
Group #
*
Screening Questions
Please answer day of vaccination:
*
Yes
No
Don't Know or N/A
Do you feel sick today?
Do you have any allergies to medications, foods (i.e. eggs), latex, or a vaccine component (i.e. gelatin, neomycin, polymyxin, yeast, thimerosal, etc.).
Have you ever had an allergic reaction to another vaccine or an injectable medication?
Do you have long-term health problems, such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease, anemia or other blood disorder?
Have you had a seizure, a brain or nervous system disorder or Guillain Barre Syndrome?
Have you received any vaccinations within the past four weeks?
Are you pregnant or considering becoming pregnant in the next 30 days?
Please list allergies (if applicable)
Please specify any long-term health problems (if applicable)
Signatures
Relationship to recipient
Signature (click and drag to form signature)
*
Clear
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: