Meredith College FLU Consent Form 01/25/23

Please fill out this form if you would like to receive a FLU SHOT!

Appointment

Patient Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

E-Mail Address*

Confirmation Emailexample@example.com

Cell Phone*

GUARDIAN/GUARANTOR INFORMATION (Only for Patient under 18 years of age - List person responsible for bill – use full legal name, no nicknames)*

Date of Birth*

Date

Primary Care Physician Name*

Primary Care Physician Phone Number*

Please enter a valid phone number.

Insurance Company Name* (if paying cash, please indicate “Self-Pay”)*

Subscriber Name/Policy Holder Name*

Subscriber Date of Birth/Policy Holders Date of Birth*

Date

Policy ID/Member Number/Subscriber ID*

Pharmacy BIN No. (RX BIN - 6 digit number)*

Pharmacy Group No. (RXGROUP) IF NO GROUP INFORMATION WRITE NO GROUP *

Please Upload a Photo of your Insurance Card*

Person to Notify in Case of Emergency*

Emergency Contact Phone Number*

The following questions will help us determine if there is any reason we should not give you or your child an injectable influenza vaccination today. If you answer “yes’ to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask us to explain.

1. Is the person to be vaccinated sick today?*

YesNo

If yes: Does the patient have a fever?

YesNo

2. Does the person to be vaccinated have any allergies?*

YesNo

If yes, what:

3. Does the person to be vaccinated today have or ever had:

a. an allergy to egg protein?*

YesNo

b. a sensitivity to Thimerosal, a preservative used in vaccines, or gelatin?*

YesNo

c. a sensitivity to latex rubber?*

YesNo

d. a serious allergic reaction or other problems after getting an Influenza (Flu) Vaccine?*

YesNo

e. a history of Guillain-Barre Syndrome (GBS)?f. an active neurological disorder?*

YesNo

f. an active neurological disorder?*

YesNo

g. a bleeding disorder(hemophilia or thrombocytopenia) or is he/she on anticoagulant therapy?*

YesNo

4. Is the person to be vaccinated immunocompromised (i.e. HIV positive) or taking immunosuppressive medication (i.e. on steroids, a transplant patient)?*

YesNo

5. If the person to be vaccinated is female, are they pregnant?*

YesNo

6. If the person to be vaccinated is a child, are they less than 9 years of age?*

YesNo

I authorize the release of any information concerning my or my child’s health care, advice and treatment provided for the purpose of evaluating and administrating claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to InClinic Rx, Eastern Carolina Medical Center Pharmacy, Avance Care Pharmacy, Hague Pharmacy at CHKD and other subsidiaries

I hereby consent to getting a vaccine given by InClinic Rx, Eastern Carolina Medical Center Pharmacy, Avance Care Pharmacy, Hague Pharmacy at CHKD and other subsidiaries

I have read the vaccine information statement and have had a chance to ask questions that were answered to my satisfaction. I understand the risks and benefits of the influenza vaccine. I understand that I will be asked to stay up to 20 minutes after I receive my flu shot. I ask that the influenza vaccine be given to me.

CLICK BELOW LINK FOR CURRENT VIS

FLU - VACCINE INFORMATION STATEMENT

Signature*

Name of the Patient or Parent of minor or Legal Guardian*

Date

Flu Clinic Location -Meredith College