Fall 2022 Flu Vaccine Consent Form

Clinic Date:*

Name*

First nameMiddle NameLast Name

Date of Birth*

Date

Age*

Address*

Address

Street Address Line 2

CityState

Zip Code

Race:*

Ethnicity:*

Hispanic/LatinoNon-Hispanic/LatinoUnknownPrefer not to answer

Gender*

Phone Number*

Email

example@example.com

Mother's Maiden Name (used for KS vaccine registry records)*

Primary Care Physician

Information on Flu vaccines can be found here:

Flu: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf

Which Vaccine would you like to receive today? (Select all that apply.)*

FluHigh Dose Flu (ages 65+)

Are you feeling sick today (if filling out the form prior to your clinic date, select no and make sure to tell the vaccinator on the day of if you do feel ill)?*

YesNo

Have you ever had an allergic reaction or a severe reaction to any vaccination or injectable medication?*

YesNo

Have you ever had an allergic reaction to something other than a componentof a vaccine or injectable medication?*

YesNo

If yes, to any allergies please list the allergy. blanks

Have you received a vaccine in the last 30 days?*

YesNo

If you have received a vaccine in the last 30 days, please list the vaccine. blanks

Do you have a bleeding disorder or are you taking a blood thinner?*

YesNo

Are you pregnant or breastfeeding?*

YesNo

Rx BIN

Rx PCN

Rx Group

Cardholder ID number

Social Security Number

Drivers License Number

State of Issuance

Medicaid ID number

State of Issuance

Medicare ID:

Social Security Number:

Please upload image of Insurance card if possible.

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I understand the benefits and risks of the flu vaccine as described in the vaccine information sheet, a copy of which I was provided with this consent and release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this consent and release.

Patient consent/signature (or parent/guardian if patient is under 18)*

Clear

Name of parent/guardian if patient is under 18:

First NameLast Name

Date of Consent*

Date

Wichita USD 259 Flu Vaccine Consent Form

Patient Information

Patient Screening Questions

Insurance Information