Fillable Student Flu Vaccine Consent Form - Delaware General Health District printable pdf download

Delaware General Health District

Full School Name:

Grade:

Student Flu Vaccine Consent Form

Teacher:

First

Middle Initial:

Name:

Last

Gender:

Name:

Apt#

Address:

City:

Zip:

State:

Phone:

Birthdate:

Age:

home

cell

work

Race:

Email:

Ethnicity (

Hispanic/Latino

Not Hispanic/Latino

American Indian/Alaskan Native

please select one:)

PATIENT DOES HAVE HEALTH INSURANCE

PATIENT DOES NOT HAVE HEALTH INSURANCE

(please fill out information below)

PRIMARY Insurance Company:

Member/Subscriber ID:

Group#

Claim Submission Address

(see back of card):

Primary Insured Name:

Relationship to Patient:

Birthdate:

Social Security Number:

Address of Primary Insured

(if different from patient):

SECONDARY Insurance Company:

Member/Subscriber ID:

Group#:

Claims Submission Address

(see back of card):

Secondary Insured Name:

Relationship to Patient:

Birthdate:

Social Security Number:

Address of Secondary Insured (

if different from patient

ONLY THE FLU SHOT IS AVAILABLE

Please answer the following questions:

1. Are you sick today?

Yes

2. Are you allergic to eggs? (Can’t eat eggs)

Yes

3. Have you ever had a serious reaction after receiving a vaccination? (difficulty breathing,

swelling of the tongue, lips or throat)

Yes

4. Have you ever had a paralyzing illness (Guillain Barre Syndrome) after a flu vaccination?

Yes

5. If under age 9 years, has your child received 2 or more flu vaccines in their life time?

Yes

The Delaware General Health District may keep this record in your medical file. DGHD will record what vaccine was given, the date the vaccine was given, the name of the

company that made the vaccine, the vaccine lot number, the signature and title of the person who gave the vaccine, and the address where the vaccine was given. I understand

that this information will be released to a state-wide Immunization Registry for the purpose of immunization tracking recall and recording, unless I request otherwise. I have

read or have had explained to me the information sheet about influenza disease and the influenza vaccine. I have had a chance to ask questions, and they were answered to my

satisfaction. I believe I understand the benefits and risks of influenza vaccine and ask that the vaccine be given to the person named above for whom I am authorized to make

this request. My medical information will not be shared without an authorization to release information. A copy of the Health Districts Notice of Privacy Practices (HIPAA) will

be provided and is also located on our website at . I authorize my insurance company to assign the amount payable directly to DGHD. I understand that I am

financially responsible for all the charges that are not covered under my private insurance plan. I acknowledge that any co-payment is due and payable on the date

services are received.

Parent/Guardian Name (please print clearly):

Parent/Guardian DOB:

Parent/Guardian Signature: ______________________________________________________________________(please sign after printing consent)

Relationship to Patient:

Date:

Nurses: _____NN _____IMPACT

Admins: _____Ins. Check _____NN _____IMPACT