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
               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: _______________

  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

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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