Student Flu Vaccine Consent

Seasonal Flu Shot Vaccine Consent Form
Participation in Student Flu Vaccination Program
Consent to Participate

YES, I wish to participateNO, I do not wish to participate
Student Details
Student Full, Legal Name

First NameLast Name
Student Birth Date

MonthDayYear
Date
Student Age
Student Sex
Student Social Security Number (For Superior Medicaid Only)
Parent | Guardian Details
Parent/Guardian Name (First Name Middle Initial. Last Name)

First NameMiddle NameLast Name
Relationship to Student
Home Address

Address

Street Address Line 2

CityState / Province

Zip Code
Email Address
example@example.com
Home Phone #
Cell Phone #
School Details
Name of School
Campus*
Homeroom Teacher
Student Grade
Insurance Details

The current health care laws require us to bill your insurance company for the vaccine. There will be no out of pocket expense for those insured.
Insurance Type

InsuranceCHIP/STAR/MedicaidAmerican Indian/Alaskan NativeUnderinsured (insurance does not cover vaccines)My child does not have health insurance ($10/Vaccine Administrative Fee requested date of clinic)
Insurance Company
Member ID
Group #
Policy Holder's Name
Policy Holder's Date of Birth

MonthDayYear
Date
Questions

IF YOU HAVE ANY HEALTH QUESTIONS, PLEASE CONTACT YOUR CHILD’S PEDIATRICIAN OR CALL AURORA CONCEPTS AT 936-598-3296 TO SPEAK TO A NURSE.
1) Is your child 4 years or older?
Question 1 Response
2) Do any of the following apply to your child? (If you answer YES, your child cannot receive a Flu Vaccine at school - please contact your child's doctor)

• Allergy to chicken eggs or egg products

• Life threatening reaction(s) to flu vaccine in the past Allergy to Latex

• Has had Guillain-Barre syndrome (very rare)
Question 2 Response
3) Do any of the below apply to your child?

• Has long-term health problems with weakened immune system, heart disease, lung disease (e.g. cystic fibrosis), liver disease, kidney disease, or metabolic disorders (e.g. diabetes) or blood disorders (e.g. sickle disease or thalassemia)
Question 3 Response
Signature
I acknowledge that Aurora Concepts provided me and I have been afforded the opportunity to read the Notice of Privacy Practices and CDC Vaccine Information Statement for the vaccine(s) indicated on their website: www.auroraconcepts.net under the ‘Patient Resources’ tab.

I give permission to Aurora Concepts and their administrators to give my child the vaccine in my absence, to communicate with other healthcare providers, as needed, and for data entry, billing and storage according to Texas Department of Health policies, to assure optimal healthcare for my child. I hereby release Aurora Concepts, and my child’s school district from any and all liability associated with the administration and potential side effects of the vaccine.
Name of Parent/Guardian
Signature

Clear
Use your mouse or finger to sign
Date

MonthDayYear
VACCINE ALERT
Should be Empty:

Seasonal Flu Shot Vaccine Consent Form

Participation in Student Flu Vaccination Program

Student Details

Parent | Guardian Details

School Details

Insurance Details

Questions

Signature