Patient Flu Shot Form

Flu Vaccine Form

Name of person to receive immunization:

Date of Birth:

Insurance:

ID#:

GR#:

Address:

Who is your regular doctor?

Appointment date:

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”.

1. Is this person sick today with a fever?

Yes No

2. In the past 14 days has this person been tested for Covid-19 or been exposed to Covid-19?

Yes No

3. In the past 10 days has this person had a fever, cough, headache, sore throat diarrhea or loss of taste or smell?

Yes No

4. Has this person ever had a serious reaction to a flu shot? Or allergic to any medicine? (Provider consultation is required prior to vaccination if “Yes” to above questions)

Yes No

5. Is this your child’s first flu vaccine? (children under 9 years old will need a booster in 4 weeks)

Yes No

If receiving flumist please answer these additional questions:

1. Is this person between the ages of 2 and 49?

Yes No

2. Does this person have a serious allergy to eggs or egg products?

Yes No

3. Does this person have severe asthma/lung disease?

Yes No

4. Is this person wheezing today?

Yes No

5. Does this person take aspirin?

Yes No

6. In the last 4 weeks has this person received the MMR, MMRV or Varicella vaccine?

Yes No

7. Is this person pregnant?

Yes No

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.

Signature:

Date:

Your information will be encrypted.