Influenza Vaccine Intake Form

PATIENT INFORMATION

Please Enter in School of Patient

Last Name:

First Name:

MI:

Social Security Number:

Date of Birth:

U.S. Military Service

None Currently Serving Discharged

Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Email:

Marital Status

Single Married Widowed Separated Divorced

Primary Language Spoken:

Limited English

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

Self Spouse Natural Child Parent Foster Child Foster Parent

Gender (Select One):

Male Female Choose Not To Disclose

Are you a migrant/seasonal worker or a family member of a migrant/seasonal worker?

Yes No

What is your annual income?

$0-$15,060 $15,061-$18,225 $18,226-$22,590 $22,591-$26,355 $26,356-$30,120 $30,121 & 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 and Release Statement

I have read or have had explained to me the above information and received a copy of the Vaccine Information Statement(s) for the Influenza vaccine. I have had a chance to ask questions which were answered to my satisfaction. I believe that I understand the benefits and risks of the Influenza vaccine and request that the vaccine be given to me.

Signature of patient

Date:

Your information will be encrypted.

Influenza Vaccine Intake Form | Telehealth

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

INSURANCE COMPANY – INCLUDING MEDICAID

Assignment and Release

Consent and Release Statement