(STORE) Influenza Consent Form 2022-2023

Influenza Vaccine

Consent & Release Form
Section 1 of 3 - Recipient Information

All 3 sections are required for each vaccine recipient. All information is protected under HIPAA privacy laws.
Recipient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
NOW *

Month Day Year
Date
Age
Gender *

Male Female
Phone Number *

Area Code Phone Number
Preferred Contact Email *

Confirmation Email Please enter email address twice to verify. We will send important information and required documents via email.
Address *

Street Address

City State

Zip Code
PHYSICIAN (M.D) INFORMATION

Please provide your Primary Care Physician's information
Primary Care Physician's Name

First Name Last Name
M.D Office Location
(Ex. Straub, Queens, Kaiser, etc.)

Section 2 of 3 - Insurance Information

If you have medical coverage please provide the information below.
Last 4 digits of Social Security
(required for ages 65+)
Do you have Medicare Part B? *

Yes No
Medical Insurance Coverage? *

Yes, I have coverage No, I do not have insurance coverage
Medicare Part B ID#
(example format: 1EG4-TE5-MK72)
Relationship to Subscriber *

Self Spouse Dependent
Primary Insurance Plan Name *
(example: HMSA, Kaiser, UHA, etc)
Membership or Subscriber ID# *
Military Sponsor's SSN or DBN #
Subscriber's Name *
Subscriber's Date of Birth *

Month Day Year
If applicable on insurance card, please provide your:
- Rx BIN Number
- Rx PCN Number
- Rx GROUP Number
Rx BIN Number
6 digit number
Rx PCN Number
Rx GROUP Number

	YES	NO	DON'T KNOW
Have you received a flu shot in the past 5 years?
Do you have allergies to medication, food, a vaccine component, or latex?
Have you ever had a serious reaction after receiving a vaccination?
Do you have a history of Guillain-Barre syndrome? (severe temporary muscle weakness)
Any history of fainting?

Section 1 of 3 - Recipient Information