Influenza Vaccine Administration Form
Download a blank fillable Influenza Vaccine Administration Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Influenza Vaccine Administration Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4INFLUENZA VACCINE ADMINISTRATION
Name: _______________________________________________________________
Phone: (_____) ______-_________
(Last)
(First)
(MI)
Address: ____________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
□
□
Male
Female
Date of Birth:_______/_______/______
Age: ________
____________________________
Township
How did you hear about this flu clinic?
(Check all that apply)
□
□
□
□
□
□
□
Newspaper
Radio
Website
School/Work
Family/Friend
Facebook/Twitter
Other __________
I have received a copy and have read or had read to me the information contained in the appropriate Vaccine Information
Statement (VIS) about the vaccine(s) I am requesting. I have had a chance to ask questions, which were answered to my
satisfaction. I believe I understand the benefits and risks of the vaccine(s) and ask that the vaccine(s) indicated on this record
be given to me or the person named above for whom I am authorized to make this request. I have received a copy of the
Lorain County General Health District (LCGHD) Privacy Statement.
LCGHD participates in the Ohio immunization registry known as Impact - SIIS. Today’s record of immunization will be
entered in Impact - SIIS and LCGHD’s electronic health record (EHR). This information is kept confidential and is shared
only with health care providers, your insurance company, and agencies for the sole purpose of protecting your health and that
of others. The information shared includes your name, birth date, types of vaccines, and the dates they were given
.
In Jurisdiction clients:
In the event that my insurance does not reimburse LCGHD or my employer is not covering the fee for vaccine, I understand
that I am receiving a vaccine at no cost by funds provided by the taxpayers through levy funding. If I do not have insurance, I
understand I am receiving vaccine provided by the State of Ohio, and levy funding will pay for the administration fee.
Out of Jurisdiction clients:
In the event that my insurance does not reimburse LCGHD or my employer is not covering the fee for vaccine, I understand
that I am responsible for the fee and will be billed by LCGHD for any balance due. If I do not have insurance, I understand I
am receiving vaccine provided by the State of Ohio and will only pay for vaccine administration if I can afford to do so.
SIGNATURE:_______________________________________________________________
DATE:________________
(Parent or guardian’s signature if client under 18 years of age)
PRINT NAME: ______________________________________________________________________________________
FOR CLERICAL USE ONLY
Please indicate form of payment below
:
(circle one)
Insurance
(circle type)
Check
Cash
No Charge
Levy
Medicaid
Medicare
Private
ID copied
:
Yes
No
(circle one)
FOR NURSING USE ONLY
Pediatric Doses:
Clinic Location:
First Dose
Second Dose
N/A
(6mo through 8 yrs, for
initial vaccination only)
Route
:
R Del
L Del
Nasal
R Thigh
L Thigh
(circle one)
Influenza VIS 8-7-2015 given:
Signature, credentials of vaccine administrator:
LABEL:
____________________________________________________________________
Date: _______/_______/______
F://Flu Clinics/ 2015 Flu Clinics/ Influenza Vaccine Administration form (09-7-2015)
Revised 9/16/2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical