Fall 2022 Flu Vaccine Consent Form

Wichita USD 259 Flu Vaccine Consent Form

Damm Pharmacy will be at Wichita USD on 12/01/22 from 4-6pm to administer flu vaccines. Please fill out all information to the best of your ability. If you have any questions we will be happy to answer them on the date of vaccination. **If filling out this form within a few hours of the clinic, you may be asked to partially fill out a paper form on-site as we will not have a way to print them during the clinic.
Clinic Date:*
Patient Information
Name*

First nameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Address*

Address

Street Address Line 2

CityState

Zip Code
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/other pacific islanderPrefer not to answer
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
Patient Screening Questions
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
Insurance Information

Please fill out to the best of your ability and/or upload an image of your insurance card if possible.
If Commercial Insurance:
Rx BIN
Rx PCN
Rx Group
Cardholder ID number
If Uninsured please list the following:
Social Security Number
Drivers License Number
State of Issuance
If Medicaid:
Medicaid ID number
State of Issuance
If Medicare:
Medicare ID:
Social Security Number:
Please upload image of Insurance card if possible.

Cancelof
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*

MonthDayYear
Date
Should be Empty:

Wichita USD 259 Flu Vaccine Consent Form

Patient Information

Patient Screening Questions

Insurance Information