; consent_form
Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out
Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

consent_form

VIEWS: 9 PAGES: 1

  • pg 1
									                                                                                                     Influenza Vaccine Consent Form

 Last Name                                      First                       Middle Initial              Male                  Birth Date                          Age
                                                                                                        Female
 Street Address                                                  City                                  Colorado                      Zip                       Phone

 Ethnic Origin                     Black-African                                   White-Caucasian               Hispanic-Latino
                                   Asian-Pac Islander                              American Indian-Eskimo-Aleut
 Language Spoken                   English      Spanish                           Bilingual (Eng/Span)          Other
 Do you have Medicaid?                                   No            Yes                                ________________________________
                                                                                        # _______________________________________________
                                                                                                                            ________________________
 Do you have Medicare Part B?                            No            Yes            # _______________________________________________

If YES to any of the following questions, we may be unable to give you influenza vaccine today.
  1.   Have you ever had a severe (life threatening) allergic reaction? ................................................... NO                                      YES
  2.   Are you allergic to eggs? ................................................................................................................... NO             YES
  3.   Do you have an allergy to any of the components in the influenza vaccine? .............................. NO                                                  YES
  4.   Have you ever had an allergic reaction after a previous dose of influenza vaccine? ................. NO                                                      YES
  5.   Have you ever had Guillain-Barre Syndrome? ................................................................................. NO                              YES


Please answer the following questions. # 6-10 indicates some groups for which influenza vaccination
is strongly recommended.
  6. Are you a healthcare worker? ........................................................................................................... NO                    YES
  7. Are you a household contact or caregiver for a child under 5 years of age or a chronically
     ill person? ........................................................................................................................................... NO     YES
  8. Do you have a blood disorder or a weakened immune system? .................................................. NO                                                YES
  9. Do you have a chronic medical condition such as diabetes, asthma, lung or heart disease? ......... NO                                                          YES
 10. Are you a woman who will be pregnant during the flu season (between October and May)?                                                                   NO     YES

Did you read and understand the influenza vaccine information sheet? ................  NO  YES
 I have read or have had explained to me the information about influenza and influenza vaccine. I understand the benefits and
 risks of the vaccine and ask that the vaccine be given to me or to the person named below for whom I am authorized to make
 this request. I authorize the release of medical information necessary to process this claim and payment of benefits to the
 Health District. I also acknowledge that I received the Health District of Northern Larimer County’s Notice of Privacy Practices.

 Signature of person to receive vaccine or person authorized to make the request (parent or guardian):
 X _______________________________________________________ Date __________________________________

 FOR CLINIC USE ONLY
 DATE VACCINATED:                                   CLINIC SITE:
 PAYMENT LEVEL: 1 2 3 4 5 6 Full Pay
 Fluvirin Lot#                                      Sanofi Pasteur Fluzone Lot#
 Amount Paid $ _________________      Cash                               Check # __________________
  Medicare Part B     Medicaid      Employee
  Visa  Mastercard  Discover # (last four digits only) ________________ Expires __________________
 INJECTION (circle:)  Route: IM Amount: 0.5cc          Site: R L deltoid, other _____________________
 Nurse Comments:
 _______________________________________________________________________________________
 NURSE SIGNATURE:

 TAX ID # 84-0515919                                                                       Diagnosis Code: V04.81
 Procedure Code      #90658 Amount                                                                    #G0008 Amount

HDNLC 700.006 2/07, Revised 9/07, 2/08, 8/08, 10/08, 9/09, 8/10, 9/11

								
To top