Flu & COVID

Fergus County Health Department Influenza & COVID Vaccine Consent

Name

First NameLast Name

Gender:

Date of Birth

Date

Age blank

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Race:

Hispanic or Latino origin?

Email

example@example.com

Client's Doctor:

Pay Source:

Insurance Company Name:

Insurance Subscriber's Name:

Subscriber's Date of Birth:

Date

Relationship to Subscriber:

Insurance Policy Number:

Insurance card photo - Front of card

Insurance card photo - Back of card

Please indication which vaccinations you are requesting:

Are you sick today?

Have you ever had received a dose of COVID-19 vaccine?

If yes, which vaccine product did you receive?

1. Have you ever had an allergic reaction to: a component of any vaccine, vaccination or other injectable medication?

Have you had a serious reaction to a vaccination?

Do you have a history of myocarditis, pericarditis or multisystem inflammatory syndrome (MIS-C or MIS-A)?

Have you had COVID-19 within the last 3 months?

Have you received a COVID-19 vaccine before or during hematopoietic cell transplant (HCT) or CAR-T-cell therapies?

Do you have a health condition or undergoing treatment that makes you moderately or severely immunocompromised?

Have you ever had Guillain-Barre Syndrome?

I have read the Vaccine Information Sheet(s) and have had a chance to ask questions. The risks and benefits have been explained to me or the person named for who I am authorized to make this request. I give the consent without coercion or reservation.

I authorized my health care provider and a public health agency to collect and enter my immunization record into the Department of Public Health and Human Services’ Immunization Information System (IIS) or imMTrax. The IIS is a confidential, computer system that contains Immunization records. I understand that information in the registry may be released to a public health agency as well as my health care providers to assist in my medical care and treatment. I understand that I can revoke this authorization and have my record removed at any time by contacting my local health department. The above information is true to the best of my knowledge. I authorize Fergus County Health Department to bill my insurance and agree benefits be paid directly to the (Fergus County Health Department). I understand that I am financially responsible for any balance. I also authorize (Fergus County Health Department) or my Insurance Company to release any information required to process my claim(s). I also give permission to the (Fergus County Health Department) to release health care information regarding any vaccinations or reactions to the Health Care Provider I have specified.

Client Signature or Authorized Representative:

Date