Influenza/pneumococcal Immunization Consent Form

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NEW YORK STATE DEPARTMENT OF HEALTH
Influenza/Pneumococcal Immunization Consent Form
Bureau of Immunization
Name (Please Print)
Date of Birth
Sex
County of Residence
Address
City
State
ZIP
Phone
For Persons Under 19 Years Old, Mother’s Maiden Name
Medicare Claim Number
Doctor’s Name
Health Insurance Provider
Doctor’s Address
NYSIIS Permission ≥ 19 Years Old
Policy Number
Clinic/Office Site Where Vaccine Administered
No
Yes
Please complete the questions below for yourself or the person receiving the vaccine.
No
Yes
Are you currently sick with a fever?
No
Yes
Have you ever had a life threatening allergy to any component (or part) of the flu or pneumonia vaccine?
If yes, please describe:
No
Yes
Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving flu vaccine?
No
Yes
Have you ever had a pneumonia shot?
No
Yes
Are you a smoker or have a chronic medical condition such as asthma, heart or lung disease?
If yes, please describe:
No
Yes
Have you ever had a severe life threatening allergy to eggs or egg products?
No
Yes
Are you currently pregnant?
No
Yes
Do you have a history of asthma or wheezing?
No
Yes
Are you a child or adolescent receiving long-term aspirin therapy?
No
Yes
Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system
who needs special care?
No
Yes
Have you received any other vaccinations within the last 4 weeks?
No
Yes
Have you taken an antiviral medication for the flu within the last 48 hours?
Influenza Consent
Pneumococcal Consent
I have read, or had explained to me, the Vaccine Information Statement
I have read, or had explained to me, the Vaccine Information Statement
about influenza vaccination. I have had a chance to ask questions, which were
about pneumococcal vaccination. I have had a chance to ask questions, which
answered to my satisfaction, and I understand the benefits and risks of the
were answered to my satisfaction, and I understand the benefits and risks of
vaccination as described. I request that the influenza vaccination be given to me
the vaccination as described. I request that the pneumococcal vaccination be
(or the person named above for whom I am authorized to make this request).
given to me (or the person named above for whom I am authorized to make
I authorize the release of any medical or other information necessary to process
this request). I authorize the release of any medical or other information
a Medicare or other insurance claim or for other public health purpose. I have
necessary to process a Medicare or other insurance claim or for other public
received a copy of the Patient Bill of Rights.
health purpose. I have received a copy of the Patient Bill of Rights.
Signature of Recipient (Parent or Guardian)
Date
Signature of Recipient (Parent or Guardian)
Date
Area Below to Be Completed by Nurse
Influenza Vaccine
Pneumococcal Disease Vaccine
Administration Date
Administration Date
Administration Site
Left Arm
Right Arm
Nasal
Administration Site
Left Arm
Right Arm
Left Thigh
Right Thigh
Left Thigh
Right Thigh
Manufacturer & Lot Number
Dosage
0.5 ml
0.25 ml
LAIV
VIS Date
Manufacturer & Lot Number
Nurse Signature
VIS Date
Next Immunization Due:
None Needed
Other
Nurse Signature
Next Immunization Due:
Next Year
In 4 Weeks
Other
DOH-4156 (6/14)
Immunizer – White
Provider – Yellow
Patient – Pink

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