Flu Shot Liability Form - PDF by llt13004


Flu Shot Liability Form document sample

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									                                   Flu Immunization Vaccine Consent Form
                                                             (Please fill out completely)

Warning: Some people should check with a doctor before taking the flu vaccine.
Do you have:
   o Are you pregnant? If so, consult with your physician prior to
   o An allergy to eggs or egg products?
   o An allergy to Thimerosal?
   o A history of Guillain Barre Syndrome or other neurological disorders?
   o Have you previously had a severe reaction to the flu shot?
   o Do you currently have a fever?
I have read and understand the information given to me. I have had a chance to
ask questions which were answered to my satisfaction. I believe that I
understand the benefits and risks of taking the flu vaccine and I request that the
vaccine be given to me or to the person named for whom I am authorized to sign.
I hereby release all sponsors and business associated with the vaccination
program from any and all liability associated with the administration and
potential side effects of the shots.

Signature: _________________________________Date: ___________________

Name:_____________________________________ Birth date: _____________
             Last          First          Middle I.

           Number     Street                          City         State        Zip

                        Insurance Information:

Name of Insurance: ________________________________________________

Insurance ID#:_________________________________ Group #:____________________
Relationship to Policyholder:__________________________________

For Clinic Use:
Vaccine Manufacturer: Lot Number: _________________________________
Date of vaccine administration: ______________________ Clinic site: SBMC
Administered by: Gwen Franz, Clinical Coordinator     Kris Donahue
Site of Administration: Right deltoid Left deltoid
______90658 Flu vaccine                Dx: V04.81 Payment:_____________
______90471 Flu admin/com ins                     _____Cash ____Check#_______
______G0008 Flu admin/medicare                    _____Visa/MC

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