Consent for Influenza Vaccine
Name
*
First name
Last name
Home Address
*
Street Address
Facility Name or Apt number or Room number
City
State / Province
Postal / Zip Code
Date of birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Social Security Number or Medicare Number (if available)
The following questions will help us determine your eligibility to be vaccinated today.
1. Do you feel sick today?
*
Yes
No
2. Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine?
*
Yes
No
3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
*
Yes
No
4. Has the person to be vaccinated ever had Guillain-Barré syndrome?
*
Yes
No
Patient signature (Parent or gaurdian, if minor)
*
Clear
Date
/
Month
/
Day
Year
Date
Please either upload a picture of your prescription insurance card or enter the insurance information below.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please enter your prescription card information below if your are not able to upload the card:
Name of Prescription Insurance Carrier
RX BIN NUMBER from Insurance Card
RX PCN NUMBER from Insurance Card
RX GROUP NUMBER from Insurance Card
ID NUMBER from Insurance Card
Below to be filled out by Immunizer Only:
Immunizer's Name
First Name
Last Name
Vaccine Manufacturer & Lot #
Administration Site
Left Arm (Deltoid)
Right Arm (Deltoid)
Administration Date
-
Month
-
Day
Year
Date
Signature of Immunizer
Clear
PLEASE BRING YOUR INSURANCE CARD, A PHOTO ID AND YOUR CURRENT VACCINATION CARD WITH YOU
Submit
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