Intranasal Vaccine Consent Form - Kanawha-Charleston Health Department (Page 2 of 2) in pdf

INTRANASAL VACCINE CONSENT FORM

STUDENTS MAY QUALIFY FOR STATE-SUPPLIED VACCINE AT A REDUCED RATE. TO DETERMINE ELIGIBILITY, PLEASE

ANSWER THE FOLLOWING:

This child is privately insured IF YES, PLEASE GO TO INSURANCE INFORMATION

Yes

This child is enrolled in WVCHIP, IF YES, PLEASE GO TO INSURANCE SECTION

Yes

This child qualifies for Immunization through the VFC Program because he/she (check only one):

Is enrolled in Medicaid IF CHECKED, PLEASE GO TO INSURANCE SECTION

Does not have health insurance

Is an American Indian or Alaskan Native

Is underinsured (has health insurance that does not pay for vaccinations)

Primary Physician’s Name____________________________________________________________________________________

Last name

First

PLEASE PROVIDE YOUR INSURANCE, CHIP OR MEDICAID INFORMATION

Name of Primary Insurance: _____________________________________ Address______________________________________

Policy

Relationship

Holder’s Name __________________________________________________ To Policy Holder

_______________________

(Last)

(First)

(MI)

Policy Holder Date of Birth:________________ Policy ID # ________________________ Group # (if any) __________________

SECONDARY INSURANCE INFORMATION IF APPLICABLE

Name of Secondary Insurance: __________________________________ Address______________________________________

Policy

Relationship

Holder’s Name __________________________________________________ To Policy Holder

_______________________

(Last)

(First)

(MI)

Policy Holder Date of Birth:________________ Policy ID # ________________________ Group # (if any) __________________

ACKNOWLEDGEMENT OF THE NOTICE OF PRIVACY PRACTICES

The KCHD Notice of Privacy Practices provides information about how we may use and disclose your protected health information.

The Notice of Privacy Practices is subject to change. To obtain a copy of our notice you may visit our website at or by

calling (304) 348-8080. By signing this form, you acknowledge that the KCHD Notice of Privacy Practices was made available to you.

CONSENT

You must be at least 18 years of age to sign. If under age 18, a parent or guardian’s signature is required. I have read or had explained

to me the 2015-2016 Vaccine Information Statement for the 2015-2015 Influenza vaccine and understand the risks and benefits. I give

consent for my child named at the top of this form to be vaccinated with this vaccine.

_____________________________________________________

_________________________________

Signature of Parent or Legal Guardian

Date

Health Department Use Only

VFC______

KCHD______

Medical Screener Signature_______________________________________________ Date_______________________________

MedImmune Intranasal

Injection

Date

Manufacturer/Vaccine:

Intranasal

------- / ------- / 2015

Influenza

Site/Route

Vaccinated:

Lot#

Place label here

Vaccinator Signature:

_________________________________

Expiration Date:

Intranasal Vaccine Consent Form - Kanawha-Charleston Health Department Page 2

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