Immunization Consent Form BCJH

Client Name:
Bill to

Medicare Medicaid Blue Cross/Blue Shield Other Insurance Sliding fee Scale
This consent can be revoked by the client/client's authorized representative at any time unless the agency has acted in reliance upon its continued effectiveness. Without expressed revocation this consent expires within one year, or (please check) until no longer lodged at the Bay County Juvenile Home

until no longer lodged at Bay County Juvenile Home Expires in one year
I have received a copy of the Bay County Notice of Privacy Practices

I have received a copy of the Bay County Notice of Privacy Practices
Signature of Client or Authorized Representative

Clear
Relationship
Date

Month Day Year
Date
Reason for signature of Authorized Representative (instead of Client Signature):

Clear
Parent/Guardian email
example@example.com
Signature of BCHD Representative

Clear
I am refusing immunizations at this time

Refuse Other
Date

Month Day Year
Date
Last Name
First Name
Middle Initial
Age
Address

Address

Street Address Line 2

City State

Zip
Phone #
Birth Date

Month Day Year
Date
Gender

Male Female
Race

Caucasian Hispanic African American Other
Insurance Type
Card Holder Name:
Card Holder Birth Date:

Month Day Year
Date
Enrollee ID
Group #
Medicare #
Medicaid #
1. Are you allergic to eggs, thimerosal (preservative), latex or have any other allergies?

Yes No
2. Have you ever had an adverse reaction to a flu shot or any other vaccine?

Yes No
3. Have you had Guillain-Barre syndrome within 6 weeks of a flu shot?

Yes No
4. Are you sick today?

Yes No
5. Have you had MMR, Varicella, Nasal Spray Flu or any other vaccines in the past 30 days?

Yes No
6. Have you ever had a seizure or neurological problem?

Yes No
7. Have you taken cortisone, prednisone, steroids, anticancer drugs, or x-ray in the last 3 months?

Yes No
8. Have you received a blood transfusion, plasma, or immune globin in the last year?

Yes No
9. Are you pregnant or is there a chance of becoming pregnant the next 3 months?

Yes No
10. Do you have cancer, leukemia, AIDS, or any other immune system problem?

Yes No
11. Did you receive the vaccine information sheet today?

Yes No
12. Do you have any questions?

Yes No
Yes, please register my or my child's immunization history in the MCIR system.

Yes, please register my or my child's immunization history in the MCIR system. No, I do not want my or my child's immunization history registered in the MCIR system.
SIGNATURE

Clear
Legal Guardian Name:
Date

Month Day Year
Date
Should be Empty: