Season Influenza Vaccine Consent Form

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Dear Patients,

Big Trees MD is administering vaccines to help protect against virus strains like Flu and COVID-19 and RSV that are expected to circulate this year. Insurance will be billed for your vaccine, if you are insured.

If you are looking to vaccinate your child, depending on whether they’ve gotten influenza vaccines in the past, some children younger than nine years of age will need two doses of vaccine spaced about 4 weeks apart.

If you have any questions about the vaccine or the vaccination clinics, or if you'd like the vaccine but do not have insurance, please call/text VACCINE to 209-653-2135 from 8 AM to 5 PM, M-F.

Sincerely,

The Big Trees MD Team
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If you do not have insurance and you would still like to get vaccinated, please call/text VACCINE to Big Trees MD at 209-653-2135 from 8 AM to 5 PM, M-F. The remaining form is for those with insurance.
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You will need pictures of the FRONT and BACK of your insurance card(s) and, if you have one, your PHARMACY BENEFIT CARD, before continuing. If you do not have these, please go get them and take pictures of the front and back of each card so you can complete your registraton.
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The Big Trees MD Flu and COVID-19 vaccine clinics will be held BY APPOINTMENT ONLY

until the end of November.
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I am looking to get the following vaccine(s)* This field is required.
Flu Vaccine
High Dose Flu Vaccine
COVID-19 Vaccine (for 12+ years old)
RSV
COVID-19 VACCINE (for 6 mos-11 years old
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Who Is The Vaccine For?* This field is required.
Self
Family Member (Child 12 + years)
Family Member (Child 0-11 years)
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Please Fill Out Information About Who Is To Receive The Vaccine* This field is required.EACH VACCINE RECIPIENT WILL NEED THIS FORM FILLED OUT
First Name
Last Name
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Additional Information About Who Is To Receive The Vaccine* This field is required.
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Can you receive a TEXT at the number above?* This field is required.This is so we can text confirmations/reminders about vaccine appointments.
YESNO
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken?* This field is required.This means has the person receiving the vaccine ever needed an Epipen injection or had hospitalization or severe respiratory distress following a vaccination?
YESNO
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Does the person receiving the vaccine have any other serious (life-threatening) allergies?* This field is required.
YESNO
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For children 6 mo-8 yrs: Have they received 2 or more doses of influenza vaccine before?* This field is required.*Two doses given at least four weeks apart are recommended for children age 6 months through 8 years of age who are getting an influenza (flu) vaccine for the first time
YESNO
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Has the person receiving the flu vaccine ever had a serious reaction to a previous dose?* This field is required.
YESNO
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Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness?* This field is required.
YESNO
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Has the person received a live vaccine within the past 30 days (i.e. MMR, RotaTeq/Rotarix)?* This field is required.*If YES, it is recommended to space live vaccines by > 4 weeks for full efficacy
YES*NO
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I have tested positive for Covid-19 in the past 3 months.* This field is required.
YESNO
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I have had the Monkeypox Vaccine within the last 4 weeks. * This field is required.
YESNO
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I have a history of Multi-Inflammatory Syndrome* This field is required.
YESNO
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I have a history of an immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparin-induced thrombocytopenia or HIT.* This field is required.
YESNO
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I have had a history of myocarditis or pericarditis.* This field is required.
YESNO
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I have a history of thrombosis with thrombocytopenia syndrome or TTS.* This field is required.
YESNO
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CDC Influenza Vaccine Information Sheet - Page 1
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CDC Influenza Vaccine Information Sheet - Page 2
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I acknowledge I have read and understand the CDC Influenza VIS* This field is required.
YESNO
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There is not a COVID-19 Vaccine Information Statement. COVID-19 vaccine is currently available through Emergency Use Authorization (EUA) by the Food and Drug Administration (FDA). EUA Fact Sheets for Recipients shall be provided to patients at the time of vaccination.
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I understand the previous statement regarding Covid and it's use via Emergency Use Authorization.* This field is required.
YESNO
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I have had a Covid vaccine before* This field is required.
YESNO
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I have had the following type(s) of Covid-19 vaccine* This field is required.
Pfizer
Moderna
Johnson & Johnson
Novavax
A different vaccine
None
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How many doses of the Covid-19 Vaccine(s) have you had and what dates did you have them administered on?* This field is required.
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Please upload a picture of your COVID vaccination card(s)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please upload pictures of the FRONT AND BACK of your insurance cards (Medicare or primary insurance + any pharmacy benefit cards you may have)* This field is required.We will need these to bill your vaccine to your insurance.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please provide your RX Bin No. This can be found in your insurance card
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Today's Date* This field is required.
Date
Year
Month
Day
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I have had the chance to discuss the nature, alternatives, benefit, and risks of the vaccine(s) noted above. I've had the chance to ask questions and they were answered to my satisfaction. I consent to the administration of the vaccine(s) for the individual named above.
Clear
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