Influenza Immunization Questionnaire / Consent Form
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1Influenza Immunization Questionnaire / Consent Form
Patient Name _____________________________________________________
Phone (______)____________________
Street Address _________________________________________
City/State/Zip Code ________________________
Birth Date ______ /______ /______
Age Today ______
Gender F
M
History of Chicken Pox Yes No
Month
Day
Year
Race (
y)
Ethnicity (
y)
Child’s Social Security #
Check one box onl
Check one box onl
Hispanic/Latino
Caucasian
Black/African American
Asian
_______ - ______ - _______
Not Hispanic/Latino
American Indian/Alaskan Native
Pacific Islander
Required to access you child’s Immunizations records online
* Please include a copy of the front and back of insurance card
Insurance Status (
)
Check one box only
Insured:
Insurance Company:____________________________ Insurance/ID #:_______________________
Group #:________________ Policy Holder Name:_________________________ Birth Date: ____/____/_____
Medicaid #
NV Check Up #:
Medicare #:
□
My Medicare is under my spouses coverage
Uninsured / No insurance
Insured, but vaccines are not a covered benefit
*
*
Please include $20 for administration fee or whatever you can afford
Please include $20 for administration fee or whatever you can afford
Please answer the following questions about THE PERSON to be vaccinated
1. Sick today?
YES
NO
2. Allergic to eggs, latex, food, medication, vaccine ingredients?
If yes, list:
YES
NO
3. Had a serious reaction to or fainted with previous immunization?
YES
NO
4. Had Guillain-Barre syndrome in the past?
YES
NO
5. Had seizure or other nervous system problem?
YES
NO
6. Have cancer, AIDS or other immune system problems?
YES
NO
7. Taken cortisone, prednisone or any steroids, anti-cancer drugs, or radiation in the last 3 months?
YES
NO
8. Received antiviral drugs in the last 3 months?
YES
NO
9. Received any other immunizations, including influenza, in the last month?
If yes, list:
YES
NO
10. Received a blood or blood product transfusion, or been given immune (gamma) globulin in the last year?
YES
NO
11. Have long-term medical problems: diabetes, heart, kidney or lung disease, asthma, wheezing or blood disorders?
YES
NO
12. Pregnant or plan to become pregnant in the next month?
YES
NO
13. Been vaccinated against influenza (flu) in the past?
YES
NO
14. Vaccine to be received today:
Either Nasal of Shot
Nasal
Shot
I have received and understand the vaccine information sheet(s) for the immunization(s) to be administered. I authorize CCHHS to enter this information
into the Nevada Immunization Registry, unless otherwise specified. I understand the CCHHS Notice of Privacy is available at
I hereby authorize & direct payment of medical benefits to CCHHS for any services
provided to me or my dependents. If my carrier deems these services non-payable, I agree that I am financially responsible for any outstanding balances.
Client/Parent/Guardian Signature
________________________________________________
Date _____/______/_________
Client/Parent/Guardian Print Name
_______________________________________
Email: _______________________________
Parent signature required if under 18 years old
CLINIC USE ONLY – DO NOT WRITE BELOW THIS LINE
Circle Location Below
Administered by: _____________________________ Date: ____/_____/_____ Clinic Location: _______________________
(Write Legibly)
First Initial
Last Name
Credential
Amount $: __________
$ Reconciliation:
WebIZ:
eCW/Scan:
RN eCW:
Cash
Check CC
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