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 (See link on Juvenile Home website)
I have received a copy of the Bay County Notice of Privacy Practices
Signature of Client or Authorized Representative
Relationship
Date
-
Month
-
Day
Year
Date
Reason for signature of Authorized Representative (instead of Client Signature):
Parent/Guardian email
example@example.com
Signature of BCHD Representative
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? (See link on Juvenile Home Website)
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
Legal Guardian Name:
Date
-
Month
-
Day
Year
Date
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