Patient Flu Shot Form

Pediatric Services 2020-2021 Flu Season

Please correct the errors described below.

Flu Vaccine Form

This form must be submitted prior to immunization. Please see the VIS sheet that was sent to your patient portal or you can review the current VIS sheets on our website or obtain one when you are in the office. If you are a parent, this immunization does not constitute a “doctor-patient relationship”.

If receiving flumist please answer these additional questions:

Consent to treat: I accept this vaccine voluntarily and consent the vaccine be given to me or my child. I have read the VIS sheet provided. I understand the risks and benefits of this vaccine. I have had an opportunity to ask questions that have been answered to my satisfaction. I hereby waive any claim for damages that I (or anyone claiming on my behalf) may have against Pediatric Services, PA, its members, employees, and agents on account of any injury or misfortune I may suffer as a result of this vaccine.

Assignment of benefits/payment for services: I authorize payment of any and all benefits to Pediatric Services, PA. I accept financial responsibility for any charges related to my care that are not covered by my insurance plan. I will cooperate with Pediatric Services, PA to secure payments due for my care. Any outstanding balance at Pediatric Services, PA, will be paid prior to any refunds due to me. Pediatric Services, PA will subsequently issue any remaining balance to me.

Patient Rights and Privacy Practices: You and your family’s rights and our privacy practices are posted in main areas of the clinic. Your signature acknowledges receipt of our Notice of Privacy Practices. If you have any questions concerning your rights and/or our privacy practices please request a copy from the front desk.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.