Microsoft word - adult consent form 2013

Clinic Site: __________________________ Flu Prevention Program
2013 ADULT INFLUENZA IMMUNIZATION CONSENT
Patient Name
Date of Birth
(As it appears on insurance card)
____/____/____
Age: _________
Address:
No. and Street Name (No PO Box Please)
City State Zip
Home or Cell Phone:
Work Phone:
PRIMARY INSURANCE INFORMATION: Please check your insurance; fill in your insurance ID# and policyholder’s name.
CONNECTICUT STATE INSURED EMPLOYEES ONLY
Insurance ID
Name of insured person if other than patient: ________________________________________________________

Direct Payment:
STAFF USE ONLY
Additional Medicare Plan: ______________________________ This is a Medicare Advantage Plan
Policy #: __________________________________________________ I understand I will receive a bill from WCHC for any portion of this claim my insurance company
does not pay and I agree to pay the bill in full within 30 days of receipt.
PLEASE ANSWER THE FOLLOWING QUESTIONS
1. Have you had a severe allergic reaction (including but not limited to hives) to eggs, latex or the preservative thimerosal? 2. Have you ever had a reaction to any vaccine? If yes, which vaccine. ______________________ Yes No 3. Have you ever been diagnosed with Guil ain-Barré Syndrome? 4. Are you sick with a fever of >100 degrees today? UNDER AGE 50 ONLY: Answer the following ONLY if you are interested in receiving FLUMIST.
A. Do you have chronic health issues such as: diabetes; heart, lung, kidney or liver disease; COPD or asthma, or a neuromuscular/neurological diseases? B. Are you in close contact with an immunosuppressed person who requires protective isolation? C. Are you pregnant or is there a chance you might be pregnant? D. Have you taken an antiviral medication such as Tamiflu® or Relenza® within the last 48 hours? E. Have you been immunized with a live vaccine (MMR, chicken pox, shingles, yellow fever or oral typhoid) I have read the Influenza Vaccine Information Statement dated 07/26/2013. I have had a chance to ask questions and I understand the benefits and risks of the vaccine. I request that the vaccination be given to me (or to the person for whom I am authorized to make this request). I authorize the release of any medical or other information necessary to process the insurance claim or for other public health purpose. I have read the Notice of Privacy Practices. I agree to pay all unpaid charges billed to me by Western Connecticut Home Care.
Signature: ________________________________________ Print Name: ________________________________________
STAFF USE ONLY

Place vaccine label here or complete: Vaccine Brand:______________________________ Lot #: ___________________ Exp. Date:____________
Site: L Arm R Arm Intranasal
Administered by: ___________________________
Date: ______ / ______ / ______

Source: http://www.westonk12-ct.org/uploaded/Health_2009-10/ADULT_CONSENT_FORM_2013.pdf