Influenza Vaccination Consent
ADVERTISEMENT
1□
Billed
□
INFLUENZA VACCINATION
AR
ASSESSMENT & CONSENT FORM
Yes No
□ □
Have you ever had a reaction to a flu shot?
□ □
Are you allergic to eggs, egg products, latex, or thimersol
?
(found in some eye cosmetics, ear, nose & eye meds)
□ □
Are you sick with a fever greater than 100 degrees Fahrenheit?
□ □
Do you have a history of Guillain-Barre' Syndrome
or any other neurological disorder?
(a neurological disorder)
□ □
Have you ever had a severe allergic reaction?
, i.e. hives, breathing difficulty, shock, requiring emergency medical
(food, medicine, flu shots, other)
treatment or within 48 hours of a previous vaccine? If yes, specify ______________________________
□ □
Have you taken an antiviral agent (a Tamiflu: generic name oseltamivir, Relenza: generic name zanamirivir or Rapivab: genric name permaivir)
in the last 48 hours?
□ □
Have you had another immunization in the last 14 days? If yes, please list ________________________________________
□ □
Do you have a bleeding disorder (
)?
thrombocytopenia, low platelet count
□ □
Are you currently undergoing Chemotherapy? Last tx? __________ Next tx date? __________
QUESTIONS
If you have any questions about the Influenza Disease or the Influenza Vaccination, please ask the nurse for clarification now or call your doctor before
requesting the vaccine. If you have any questions or concerns following the vaccination, please call the MC VNA at 248-967-1440. If you experience any
adverse effects from the Influenza Vaccination, please contact your physician and notify the MC VNA (also notify your employer if you received your
vaccination at work).
CONSENT AND RELEASE FOR INFLUENZA VACCINE
• I have read the Vaccination Information Sheet regarding the Influenza Vaccine. I have had an opportunity to ask questions, and my questions have been
answered to my satisfaction. I understand the benefits and risks of the Influenza Vaccination as described. I request that the vaccine be given to me. I
understand the vaccination is being provided by MC VNA. I expressly release MC VNA from any liability resulting from the Influenza Vaccine.
• I agree to remain under observation for at least 15 minutes. Should I leave before that period lapses, I expressly release MC VNA from any liability
resulting from any adverse reaction to the vaccine which may occur during that period and thereafter. I understand that if I experience any side effects, it
will be my responsibility to follow up with my physician at my expense. I understand side effects may include, but are not limited to: soreness at the
injection site, fever, fatigue and headache. There is some risk for Guillain-Barre Syndrome. Severe reactions may include anaphylaxis and death.
• In the event a MC VNA employee is exposed to my blood or other body fluids, I agree to have my blood tested for HIV and Hepatitis and have the results
released to MC VNA/exposed person, but not to anyone else unless required/authorized by law.
• I acknowledge that I have received written information on MC VNA’s “Notice of Privacy Practices” prior to the provision of service, and I have had the
opportunity to have my questions answered.
• I wish to have MC VNA bill my insurance for the cost of my shot. MC VNA agrees to accept provider payment.
• I acknowledge that I am responsible to reimburse the MC VNA for charges not covered by my insurance.
CLIENT INFORMATION
□
□
Legal Name
M
F
Birthdate
Age
Weight (if < 110 lbs)
(as it appears on card)
Street Address / Apt. No.
City
State
ZIP
Telephone
□
□
□
Medicaid
Client has one of the following insurance plans with VACCINE COVERAGE?
Medicare Part B
BCN
□
□
□
□
□
□
□
HAP
BCBS
COPS Trust (SOM)
PHP
Priority Health
HealthPlus
McLaren
Insurance Contract #
Responsible Party or Cardholder Information
Responsible Party Birthdate
Signature of Client/Guardian
Date
Email Address
□
I have received a flu shot in the past?
Yes
□
No
Clinic Name/Date:
TO BE COMPLETED BY CLINIC STAFF
Dose 3 Years & Older
Dose 6 - 35 Mths FluZone
High Dose 65 Years & Older
0.5 cc Quadrivalent A & B
0.25 cc Quadrivalent A & B
0.5 cc HD Trivalent A & B
□
□
□
Right Deltoid IM
Right Thigh IM
Right Deltoid IM
□
□
□
Left Deltoid IM
Left Thigh IM
Left Deltoid IM
□
Right Thigh IM
□
Left Thigh IM
Manu/Lot #/Exp
Nurse Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal