PATIENT INFORMATION SHEET Please Print Legibly Patient Name _________________________________________________________________________________________________________ Last First Middle Initial The Name You Prefer To Be Called _________________________________ Student I.D. # __________________________________________ Date of Birth _____/_____/_____ Your Age Today ______ Gender Female Male Current Address _______________________________________________________________________________________________________ Street City State Zip Code Permanent Address ____________________________________________________________________________________________________________________ Street City State Zip Code Home Phone # (___) ____-________ Work Phone # (___) ____-________ Other Phone # (___) ____-_______ CONDITIONAL AGREEMENT I understand: Confidentiality – 1. All information contained in my medical record is confidential and will be treated as such. The Student Health Clinic cannot release any information regarding my medical treatment without my express written consent (release) except as required by law. Payment for Services and Financial Arrangements – 1. The Student Health Clinic charges for laboratory, certain treatments and procedures, and injections including vaccines. a. I am responsible for making full payment at the time services are received. b. I agree to make full payment for services at time of service or within 10 days of service. If not paid within 10 days, any unpaid balance on my account will result in my school records and registration being put on hold until the debt is paid. Treatment and Services – 1. All SHC providers are subject to the provisions of the Utah Governmental Immunity Act, Section 63-30-1, et seq, UCA 1953 as amended, which controls all procedures and limitations with respect to any claim of liability or malpractice. a. All medical care will be provided by, or under the direction of a Family Nurse Practitioner. b. Because the Student Health Clinic may be a teaching center for family nurse practitioners, graduate students may be involved in your care. SLCC students in the medical assisting program and/or the nursing program may also be involved in your care. 2. By seeking services at SHC, I give my consent to have a H1N1 vaccine administered. I have read the vaccine information sheet provided. I understand the risks and benefits and have had a chance to ask questions to my satisfaction. I am the person, or I am legally responsible for the patient whose name appears below. I have read this entire document and understand my signature constitutes acceptance of the terms as written. Patient Signature: _____________________________________ Date: _______________ SLCC STUDENT HEALTH SCREENING QUESTIONNAIRE FOR ADULT IMMUNIZATION PATIENT NAME: ____________________________________________________ DOB:________________ TO THE PATIENT: The following questions will help us determine if the influenza vaccine may be given today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it. Yes No Don’t Know Are you sick today? Do you have any allergies to eggs or to a component of the influenza vaccine? Have you ever had a serious reaction after receiving an intranasal influenza vaccination (FluMist) or had Guillain Barre Syndrome? Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long-term treatment with radiation or drugs? Have you received any vaccinations within the past 4 weeks? For Women: Are you pregnant or is there any chance you could become pregnant during the next month? Are you younger than 2 years or older than 49 years? Do you have a long-term health problem with any of these diseases: heart, lung, and asthma, kidney, neurologic or neuromuscular, liver, metabolic (e.g., diabetes), anemia or another blood disorder? Do you live with or expect to have close contact with a person whose immune system is severely compromised and who must be a protective isolation (such as in a hospital room with reverse air flow)? Form Completed By: X Form Reviewed By X Staff notes: Vaccine Type of Date given Route/ Box# Vaccine Lot# VIS Signature Vaccine (mo/day/yr) Site Dose # and Mfr. Date on / initials of (generic and Date vaccinator abbreviation) given Intranasal LAIV Intranasal/ Lot: 500804P 10/ Influenza A (live nasal Ex: 2/23/09 02/ H1N1 attenuated) Medimmune 09 90470stu 90470pts 90470fts Influenza A H1N1 vaccine $5.00 CHARGES FOR SERVICES ARE DUE AT TIME OF SERVICE Amount Due: $___5.00_______ FORM OF PAYMENT: □ CHECK#________□ CASH □ CREDIT CARD □ CASHIER’S □ NO CHARGE PAYMENT RECEIVED $__________________ RECEIVED BY:_____________________________ I understand that I will be responsible for any charges incurred at this visit. Payment in full or the unpaid balance of $______________________ is due within 10 business days. I also understand that no other bill will be sent. A hold will be placed on my student account if this bill is not paid by _____________________.
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