Seasonal Influenza Vaccine Program - Child Form (6mos Thru 18 Years Of Age) printable pdf download

Office Use only:

_________

PLEASE PRINT: CHILD FORM (6mos thru 18 years of age)

Client ID#

Macomb County Health Department Seasonal Influenza Vaccine Program

Today’s Date:________________

Child’s Birth date: _____________________________________

Child’s Sex (Circle One): Male

Female

Child’s Legal Name: ____________________________________________________________________________________

(Last)

(First)

(Middle)

Race: __White __Asian ___Black/African American ___Multiracial

(If multiracial checked, please circle all that apply)

___Native Hawaiian/Pacific Islander

__Native Alaskan/American Indian

Ethnicity (Circle if applies): Hispanic

Parent/Responsible Party: _______________________________________________________________________________

Street Address: ________________________________________________________________________________________

City:_______________________________________ State: ________ Zip: _______________ County:__________________

Telephone #: ________________________________________________

(Area Code)

Is your child enrolled in any of the following?

____ Medicaid

____ No Medical Insurance

____ Commercial Insurance that does cover immunizations (circle)

BCBS OF MICHIGAN BCN

HAP MCLAREN

OTHER___________

____ Commercial Insurance that does not cover immunizations

THIS SECTION TO BE COMPLETED FOR COMMERCIAL INSURANCES ACCEPTED BY MACOMB COUNTY HEALTH DEPARTMENT:

I authorize any holder of medical information about my child/me to release to commercial insurance or their Intermediaries or carriers,

information needed for this claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical

insurance benefits to the party who accepts assignment below.

______________________________

Parent/Guardian/Client Signature X

Macomb County Health Department Accepts Assignment

Medical Screening Questionnaire and Consent for Vaccination

Please circle the answer to the following questions about you or the person to be vaccinated:

YES

1. Ever had a serious reaction to a vaccine?

YES

2. Allergic to eggs, Thimerosal, gelatin, or any antibiotics?

YES

3. Receive an influenza vaccination during any past flu seasons?

4. Ever had Guillain-Barré Syndrome (GBS)?

YES

5. Have any long-term health problem such as heart or lung disease, kidney disease or metabolic

disease (diabetes)?

YES

6. Have severe thrombocytopenia (low platelet count) or a bleeding disorder?

YES

7. Currently ill or running a fever?

YES

8. Have asthma or have you/your child had a recent episode of wheezing in the past 12 months?

YES

9. Currently receiving aspirin therapy?

YES

NO 10. Are or may be pregnant?

YES

NO 11. Received any vaccine within the past 30 days?

YES

NO 12. Have cancer, leukemia, lymphoma, or any immune deficiency disease (inability to fight infection) or

currently receiving chemotherapy, radiation therapy or steroid therapy (prednisone or cortisone)?

YES

NO 13. Have close contact with anyone who has a severely weakened immune system (for example, an

individual who has had a bone marrow transplant and is currently in a hospital isolation room)?

I have read or have had explained to me, the information contained in the Vaccine Information Statement(s) regarding the

vaccine(s) to be administered today. I have had a chance to ask questions which were answered to my satisfaction. I believe I

understand the benefits and risks of the specific vaccine(s). I ask that the vaccine(s) be given to me, or to the person for whom

I am authorized to make this request. I also authorize the Macomb County Health Department to release my immunization

record information, or the immunization record information of the person for whom I am authorized to make this request to

other health care provider(s) as needed.

Macomb County Health Department Notice of Health Information Practices

I have received a copy of Macomb County Health Department’s Notice of Health Information Practices. I understand that my

acknowledgement of the Notice is evidenced by my signature on this document. The Department is required to abide by the

terms of this privacy notice. The Department may change the terms of its notice at any time. The new notice will be effective for

all protected health information that it maintains at that time. Upon my request, the Department will provide me with the revised

notice of privacy practices.

__________________________________________________

____________________________________________

SIGNATURE of Parent/Legal Guardian

PRINT NAME of Parent/Legal Guardian (if applicable)

_____Received Notice of Health Information Practices

______REFUSED written acknowledgement

9-18-14 CHILD

C:\Documents and Settings\mswiat\My Documents\Downloads\CHILDVaccineFLUForm 2014.doc

Seasonal Influenza Vaccine Program - Child Form (6mos Thru 18 Years Of Age)

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