INSURANCE POLICY HOLDER INFORMATION

							                                          LAMOURE COUNTY HEALTH DEPARTMENT INFLUENZA VAR
                                              PO Box 692, LaMoure, ND 58458 701.883.5356
Client Last Name                First Name                Middle                                              Date of Birth:          Age:     Gender:   Birth State
                                                                                                                                                Male
                                                                                                                                                Female
Address (Street or P.O. Box):                                          City:                                  County:                 State    Zip Code:


Parent/Guardian Name:                                       Home Phone #                                      Cell Phone #

Race: ___American Indian or Alaska Native                                ___Hispanic/Latino                   MOTHER’S INFORMATION:
      ___Asian                                                           ___Other Race                     Name: ________________________________________
      ___Black or African American                                       ___Unknown                                  First           Middle          Last
      ___Native Hawaiian or other Pacific Islander                       ___White                          Mother’s Maiden Name: ______________________
Payment Status (Check all that apply):
Vaccination fee can be billed to your insurance or Medicaid, or paid in cash/check.
 Medicaid Eligible - Please write Medicaid #: __________________             Primary Insurance                            Secondary Insurance
 No Insurance              Underinsured (Vaccines not covered by health insurance)
                                               INSURANCE POLICY HOLDER INFORMATION
Last Name: ________________________________ First Name: _______________________ Middle Initial: __________
Date of Birth: _______________ Gender  Male  Female Policy Holder Relationship to Child: ________________
Address of Policy Holder if different than Child: _________________________________________________________
Insurance Company Name and Address: _________________________________________________________________
____________________________________________________________________________________________________
                                                                                                  (City)                          ( State)               ( Zip)
Policy Number: __________________________________                               Group Number if Applicable: ________________________
HAS OR DOES THE CHILD RECEIVING THE VACCINE:
        □ Yes    □ No     Had any problems after receiving previous vaccines?
        □ Yes    □ No     Have any allergies to latex, eggs, other food, medicine, or any vaccine (please list)?
        □ Yes    □ No     Have a brain problem, ever had a seizure or Guillian-Barre´ syndrome?
        □ Yes    □ No     Have a serious long-term health problem such as heart, lung, liver, kidney, neurologic, metabolic (diabetes)
                                   disease or blood disorder?
        □ Yes    □ No     Received any blood products or Immune Globulin in the past year?
        □ Yes    □ No     Have a weakened immune system because of HIV/AIDS or another disease that affects the immune system,
                                   long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs?
        □ Yes    □ No    Received any vaccines in the past 4 weeks?
IS THE CHILD TO BE VACCINATED:
          Yes     No    Receiving aspirin therapy or antiviral medications?
          Yes    No    Living with or expected to have close contact with a person whose immune system is severely compromised and
                                   who must be in protective isolation (e.g. an isolation room of a bone marrow transplant unit)?
        □ Yes    □ No    Sick today?
        □ Yes    □ No     Pregnant or think she may become pregnant in the next 4 weeks?

IF YOUR CHILD IS UNDER THE AGE OF 9, DID HE/SHE RECEIVE AN INFLUENZA VACCINATION LAST YEAR? YES                                        NO
If “no”, your child will need two vaccinations this year to be fully immunized. Please initial in the following box to give permission to LCHD to vaccinate your child
with the second influenza vaccine in 4 weeks. Parent/Guardian Initials: ________

WHICH FORM OF THE VACCINE DO YOU PREFER YOUR CHILD RECEIVE (PLEASE CIRCLE)?                                           SHOT           MIST

ACKNOWLEDGEMENT, AUTHORIZATION AND ASSIGNMENT OF BENEFITS
I have read, or have had explained, the Vaccine Information Statement(s) about the vaccine(s) recommended and the disease(s) for which they provide protection.
There was an opportunity to ask questions; all questions were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine(s)
discussed and ask that those vaccine(s) be given to me or the person for whom I am authorized to make this request.
If I am the Client, or an individual legally obligated to pay for medical services provided to the Client or a Guarantor of payment, I agree to pay and I am financially
responsible for the LaMoure County Health Department’s established charges provided to the Client not covered by a third-party payer.
I assign and authorize any third party payer/insurer to make direct payment to the LaMoure County Health Department of all benefits payable for the Client’s care
(minor not allowed to sign). I authorize the release of any medical or other information necessary to process this claim.
  Signature of person to receive vaccine or Legal Guardian:                                              Date:                  School:




                                                                                    VIS                                                       Admin      Vaccine
                  Vaccine(s) To Be Given                             Route
                                                                                    Date           MFG
                                                                                                                Lot Number            S/P
                                                                                                                                               Site    Administrator
     Influenza Inactivated (TIV)
                                                                       IM        7/26/11            SP
     Influenza Live Intranasal (LAIV)
                                                                      nasal      7/26/11      Med Imm

1.   Indicate if state-supplied or privately purchased: S = State-supplied, P = Privately purchased
2.   Site Vaccine Given: LA = Left Arm, RA = Right Arm, LUT = Left Upper Thigh, LLT= Left Lower Thigh, RUT = Right Upper Thigh, RLT= Right Lower Thigh

Tobacco Use (circle those that apply): Never     Current User         Former User      Second Hand Smoke

                                       Precontemplative      Contemplative        Preparing       Action    Maintenance

                                       Fax Referral to Quitline/net     Quitline/net Info Given     Secondhand Smoke Info Given