Influenza Vaccine Consent Form
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Prefer not to answer
Other
Ethnicity:
Hispanic or Latino
Non-Hispanic/Latino
Unknown
Prefer not to answer
Other
Race
African American
American Indian
Asian
Caucasian
Native Hawaiian/ Other Pacific Islander
Prefer not to answer
Other
Primary Doctor Name
First Name
Last Name
Preferred Clinic/Hospital
Preferred Pharmacy
I am interested in following vaccinations:
Influenza Vaccine
Other
Insurance Information
Medicare
Commercial
Uninsured
Medicare Information
Medicare Number
Part A Date
Part B Date
Commercial Insurance
BIN Number
PCN Number
Group Number
ID Number
Insured Patients
I authorize the pharmacy to bill my insurance on my behalf for the immunization.
Uninsured Patients
I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan.
Screening for Immunization
Does the person to be vaccinated have a fever or illness today?
Yes
No
Does the person to be vaccinated have an allergy to eggs, latex, or to a component of the vaccine?
Yes
No
Has the person to be vaccinated ever had a serious reaction to this vaccine in the past?
Yes
No
Has the person to be vaccinated ever had Guillain-Barre syndrome less than 6 weeks after vaccination, uncontrolled seizures or any unstable neurological disorder?
Yes
No
Has the person to be vaccinated received any vaccines in the past 30 days?
Yes
No
Is the person to be vaccinated 6 years of age or older?
Yes
No
Is the person to be vaccinated currently pregnant, breastfeeding, or planning to become pregnant in the next 30 days?
Yes
No
Consent for Immunization
I, undersigned, agree with the followings:
I certify that the information above is correct and accurate to the best of my knowledge.
I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving.
All my questions concerning the vaccine have been answered to my satisfaction.
I understand the benefits and risks of receiving the vaccine and request that it be given to me.
I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: