Influenza Vaccine Intake Form

PATIENT INFORMATION

Please Enter in School of Patient

Last Name:

First Name:

MI:

Social Security Number:

Date of Birth:

Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Email:

Gender (Select One):

Male Female Choose Not To Disclose

Primary Language Spoken:

Limited English

Patient’s Relationship to Responsible Party (Select One):

Self Spouse Natural Child Parent Foster Child Foster Parent

Race (Select One):

American Indian/Alaska Native Asian Black/African American Native Hawaiian Other Pacific Islander White More than one Race Choose Not To Disclose

Ethnicity (Select One):

Hispanic/Latino Non-Hispanic/Latino Choose Not To Disclose

What is your annual income?

$0-$14,580 $14,581-$18,225 $18,226-$21,870 $21,871-$25,515 $25,516-$29,160 $29,161 & UP

How many people (including you) does your income support?

Emergency Contact:

Phone:

Relationship to Patient:

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

Last Name:

First Name:

MI:

Mailing Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Date of Birth

Social Security Number:

INSURANCE COMPANY – INCLUDING MEDICAID

Primary Insurance:

ID#:

Group#:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Secondary Insurance:

ID#:

Group#:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Assignment and Release

I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to process this claim.

SIGNATURE:

DATE:

Please complete the information below if you would like to receive the flu vaccine from PanCare of Florida, Inc.

Do you feel sick today?

Yes No Unknown

Have you ever had a serious allergic reaction to eggs? If yes, as a precaution, it is recommended you do not receive the flu vaccine until you have consulted your private healthcare provider.

Yes No Unknown

Have you ever had a serious reaction to a previous dose of flu vaccine?

Yes No Unknown

Have you ever had Guillain-Barre Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine?

Yes No Unknown

Are you allergic to latex?

Yes No Unknown

Are you pregnant or nursing? If so, please consult your private healthcare provider.

Yes No Unknown

Do you have a bleeding disorder (hemophilia or thrombocytopenia) or are you on anticoagulant therapy?

Yes No Unknown

Are you allergic to thimerosal (a preservative) other than contact lens sensitivity?

Yes No Unknown

Have you ever received a flu shot before?

Yes No Unknown

Consent for Treatment

I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated physicians, dentists, ARNPs, physician assistants and other medical personnel to administer examinations and treatments as deemed medically necessary.

Patient, Parent, or Guardian Signature:

Date:

Your information will be encrypted.