Influenza Vaccine Consent And Screening Form 2013-2014
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22013-2014 Influenza Vaccine Consent and Screening Form
The completion of this form is necessary for every vaccine recipient.
If no insurance information is available, please fill out as much as possible using existing information.
Information about the person to receive vaccine (please print):
*Required Fields
Name: (Last, First,
MI)*
Date of birth:
*
Age*
Sex:
(Circle)*
_____
____ _____
Male
Female
Month
Day
Year
Street
Address:*
City:*
State:
*
Zip:*
Phone:*
(
)
Insurance Information:
Include the whole member ID number and any letters that are part of that number
Name of Insurance
Company:*
Member ID
Number:*
Group ID Number: (if available)
If person getting vaccinated is not the subscriber, please complete the following:
Subscriber’s Name: (Last, First,
MI)*
Subscriber’s Date of Birth:
*
Sex:
(Circle)*
_____
____ _____
Male
Female
Month
Day
Year
Subscriber’s Street
Address:* (If different from address above)
City:*
State:*
Zip:
*
Phone:*
(
)
Patient Relationship to Subscriber:
(Circle)*
Spouse
Child
Other
I give permission for my insurance company to be billed.
X
______
________________
Date:
(Signature of patient, parent or legal guardian)
I GIVE CONSENT for me / my child named at the top of this form to get vaccinated with this vaccine.
___ Injectable only
____ Nasal mist only
____ Either injectable or nasal mist
X
______
Date: __________________
(Signature of patient, parent or legal guardian)
*************************************************************************************************************************
For Clinic/Office Use Only:
Date
Date
Date
Exp.
Dose
State
Preserv
Vax
Injection Route
Injection Site
Vax
VIS
vax
Date/ Lot
On
Suppl-
Free
Type
Manufacturer
(Circle)
(Circle)
given
given:
No
VIS
ied
07/26/13
Yes
IM
R Arm
L Arm
Yes
No
R Leg
L Leg
07/26/13
LAIV4
Medimmune
0.2 ml
Yes
N/A
Intranasal
N/A
For children 18 years of age and younger:
Is enrolled in Medicaid (includes MassHealth and HMOs, etc., if enrolled through Medicaid)
Does not have health insurance
Is American Indian (Native American) or Alaska Native
Has health insurance and is not American Indian (Native American) or Alaska Native
Clinic Site Name:
Berkshire County Boards of Health Association
MDPH Provider PIN#: 11340
Clinic Address:
1 Fenn St, Suite 302, Pittsfield, MA 01201
Signature of Vaccine Administrator: __________________________________________
Date: __________________
Flu Vaccine Consent Form
1
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