Mobile Influenza Vaccine Intake Form

Please correct the errors described below.

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

INSURANCE COMPANY – INCLUDING MEDICAID

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.

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

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.

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