Immunization Encounter Form printable pdf download

IMMUNIZATION ENCOUNTER FORM

Offsite Clinic Operator ID# _________________________

Patient Name: (First, Middle Initial, Last) ______________________________________ Date of Birth: _____/_____/_____ Age: _____

Gender:

Phone #: ______________________ SS# _________-_____-_________ Email: ____________________________

Address: _____________________________#: ________ City: ___________________ State: __________ ZIP: _______

Race:

White

Alaskan Native

Black or African American

Native American

Asian/Pacific Islander

Other

Ethnicity: Hispanic?

Health Insurance?

YES

Please have insurance information/card ready to present

Policy Holder/Subscriber Name: ____________________________________ DOB: _____/_____/_______ Relationship: ____________

Screening Questions for Today's Immunizations

Don't

Please answer these questions concerning the individual receiving immunizations today by checking the

Yes

boxes below

Know

Are you sick today and/or had a fever in the last 24 hours?

Do you have any chronic disease/condition? A child < 5 years of age with recurrent wheezing?

Do you have allergies to medications, food, latex or any vaccine?

Have you had a serious reaction to a vaccine in the past?

Have you ever had a seizure, Guillain-Barre syndrome

or other brain/nervous system problem?

Do you currently have or live with someone who has cancer, leukemia, HIV/AIDS, or any other immune system

problem; or, in the past 3 months, have you taken medications that weaken the immune system, such as cortisone,

prednisone, other steroids, anticancer drugs; or had radiation treatments?

Are you a child or adolescent taking

aspirin therapy?

Have you received a transfusion of blood or blood products, or been given an immune (gamma) globulin in the past year?

(Females) Are you pregnant or at risk of becoming pregnant within the next month?

Have you received any vaccinations in the past four weeks?

Have you ever had Chickenpox disease?

I have been given a copy and have read or had explained to me, the information contained in the Vaccine Information Statement(s) about the disease(s) and

vaccine(s). Any questions I had were answered to my satisfaction. I understand the benefits and risk of the vaccine(s) and request that the vaccine(s) indicated be

given to me or the person for whom I am authorized to make this request. I certify that I have received a copy or been given the opportunity to read the Notice of

Privacy Practices. I agree that the information on this form may be shared with schools, day care centers, health care providers, and others to verify immunization

status, for public health studies, or when medically necessary. I hereby release the Utah County Government and their employees from all claims arising from such

immunizations. I understand that if I have insurance that covers vaccines, I am not eligible for the Vaccine for Children program.

I understand that my health insurance coverage could have certain restrictions and limitations. I agree to pay the full amount for any and all related

charges, if they are not covered by my insurance for any reason. If I fail to pay for these services and charges within 90 days of receiving notice that

the charges are not covered for any reason, my account will be turned over to a collection agency. I hereby expressly agree to pay all costs of

collection fees including an additional collection of 35%. I further agree to pay all court costs and attorney’s fees should legal action become

necessary. Due to the higher cost to provide insurance billing services, I understand that the amount billed to my insurance company is higher than

the discounted amount I would have paid if I had chosen to pay at the time of service. I understand that I will be charged the full cost of the vaccines

if I do not pay today and my insurance company does not cover the costs for any reason. I hereby request and authorize the Utah County Health

Department to submit claims to my Medicaid, Medicare, and/or UCHD contracted insurances.

the terms and conditions contained within this agreement shall be governed by the laws of the State of Utah and shall be construed

JURISDICTION AND VENUE

and interpreted in accordance with those laws. Any action or proceeding brought by either party which is based upon or derived from, or in any way related to

this agreement shall be brought in a court of competent jurisdiction within the state of Utah. The parties hereto consent to their personal jurisdiction of said court.

IF RECEIVING YELLOW FEVER, TYPHOID, JAPANESE ENCEPHALITIS, CHOLERA, OR RABIES VACCINES, A NEWBORN SCREEN OR TB TEST,

I acknowledge that I have elected to be seen as a SELF-PAY PATIENT for these services. Utah County Health Department will NOT bill my insurance for these

mentioned vaccines. If I choose to seek reimbursement from my insurance, Utah County Health Department is NOT responsible for any amount that my

insurance company does not compensate. I am agreeing to assume ALL financial responsibility and to pay Utah County Health Department the total amount

due at the time of service.

Authorization Signature: _______________________________ Date:

____/____/_____

If NOT client: Please Print Name: ____________________________ DOB: _____/_____/_____ Relationship: _________________

Date printed on Vaccine Information Sheet: MULTI VACCINES 10/22/14; DTAP/DT 5/17/07; HEP A 7/20/16; HEP B 7/20/16; HIB 4/02/15; HPV9 12/2/16; IG 05/1/94; INFLUENZA

8/07/15; MENINGITIS 3/31/16; MENB 8/9/16; MMR 4/20/12; MMRV 5/21/10; PPSV23 4/24/15; PCV13 11/5/15; POLIO 7/20/16; PPD 04/25/05; RABIES 10/06/09; ROTAVIRUS

4/15/15; SHINGLES 10/06/09; TD 2/24/15; TDAP 2/24/15; TYPHOID 5/29/12; VARICELLA 3/13/08; YELLOW FEVER 03/30/11; JE 1/24/14

Vaccine

LOT #

COST

PAYMENT INFORMATION

SITE

DOSE