Staff Influenza (Flu) Consent Form
INSURANCE CARD MUST BE SENT IMMEDIATELY AFTER YOU FILL THIS FORM OUT TO VACCINE@PRECISIONLTC.COM OR BY TEXTING 516-340-0099. AN ALTERNATIVE IS TO UPLOAD THE CARD DIRECTLY ON THIS FORM BELOW.
Name
*
First Name
Last Name
Facility Name
*
Sex
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Social Security Number
*
Upload Insurance Information
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Vaccine is for (check one)
*
Self
Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers?
*
YES
NO
Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness?
*
YES
NO
Has the person received a live vaccine within the past 30 days (i.e. MMR, RotaTeq/Rotarix)? *If YES, it is recommended to space live vaccines by > 4 weeks for full efficacy
*
YES
NO
Is the person receiving the vaccine pregnant?
*
YES
NO
Is the person receiving the vaccine allergic to Neomycin, Thimerosal (Preservative found in contact lens solution), any vaccine ingredient, or latex?
*
YES
NO
Is the person being administered the regular or high-dose flu vaccine?
*
Regular Dose
High Dose (Over 65)
I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine.
*
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