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Influenza vaccine permission 2001-2002

WESTPORT WESTON HEALTH DISTRICT
Received by:
INFLUENZA VACCINE PERMISSION
PRINT CLEARLY
________________________________________________ ________________ Age ______ Male Female
Patient’s Name as it appears on your Insurance card

Date of Birth
________________________________________________________________
(_____)_________________

Last 4 digits of your SS# ____________________ Method of payment:
Cash _____ Check#_______
PROVIDE a copy of your Insurance card: Medicare B Aetna Anthem BC Cigna ConnectiCare

Name of Primary Card Holder: _________________________________ Date of Birth : _______________

Have you ever had a flu vaccination? …………………………………………….
Yes No
Have you ever had a serious reaction from a previous flu vaccination? .…. Yes No
Are you sick or do you have a fever today? ……………………………………. Yes No
Are you severely allergic to eggs, gentamicin, gelatin, argine or latex? …… Yes No
Are you allergic to thimerosal (mercury-derived preservative)? ……………. Yes No
Do you have/ had Guillain-Barre Disease? ……………………………………. Yes No
FOR FLU MIST ONLY: Please answer the questions below:
If you are younger than 5 years, have you had one or more episodes of wheezing in the past year?. Yes No
Do you have asthma or lung disease? …………………………………………………………………
Yes No
Do you have Diabetes, heart, liver, kidney, blood, or neurological disorder?. Yes No
Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune
system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or
drugs? ………………………………………………………………………….………
Yes No
Have you received any other vaccinations in the past 4 weeks? ……………
Yes No
Are you pregnant or nursing? ……………………………………………………… Yes No
Have you received any antivirals (i.e., Amantadine, Tamiflu, Relenza) in the past 48 hours? Yes No
-----------------------------------------------------------------------------------------------------------------------------------------------------------------
I have read, or had explained to me, the information sheet about the Influenza Vaccine. I have had a chance to ask questions which
were answered to my satisfaction and I understand the benefits and risks of the vaccination. I request that the vaccine be given to me
(or the person named below, for whom I am authorized to make this request).
Health information may be disclosed for the following purposes: a) to bill and receive payment for the flu vaccine you have received;
and/or b) to report any adverse reaction you may experience after receiving the flu vaccine. I authorize release of any medical or other
information necessary to process an insurance claim. I understand that if the insurance rejects payment for this vaccination that
the health district will bill me and I agree to pay the fee.

___________________________________________________
Signature of Recipient (or Parent or Guardian) FOR CLINIC USE ONLY

Clinic Site: ________________________________
Date Vaccinated: ___________________________

Manufacturer & Lot Number: ______________________________________ Exp. Date: _____________

Injection Site:  Left Arm  Right Arm
Dosage (circle one): 0.25cc OR 0.5cc OR 0.2ml Intra-nasal OR High Dose
Vaccinator’s Signature: ________________________________________________
INFLUENZA VACCINE PERMISSION 2013-14 (2).doc

Source: http://wwhd.org/downloads/fluform2013.pdf

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SURGERYSurgery is undertaken to clear lesions which cannot be managed by simpler means. As illustrated a margin of healthy tissue is re-moved around the lesion so that the lab can examine it under the microscope to determine the characteristics and complete excision. You will note that a simple excision illustrated is aligned into the skin folds for best scar results and takes the shape of an

Packet info sheet.pub

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