Influenza Vaccine Informed Consent
2022-2023
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
mm-dd-yyyy
Email
example@example.com
Age
*
Age at the time of vaccination
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Prefer not to answer
Other
Ethnicity:
Hispanic or Latino
Non-Hispanic/Latino
Unknown
Prefer not to answer
Other
Race
African American
American Indian
Asian
Caucasian
Native Hawaiian/ Other Pacific Islander
Prefer not to answer
Other
Primary Doctor Name
First Name
Last Name
I am interested in following vaccinations:
*
FLUAD High Dose Vaccine (65 years +)
Afluria Quadrivalent Vaccine
Other
Insurance Information
*
Medicare
Commercial
Uninsured
Medicare Information
Medicare Number
Part B Date
Commercial Insurance
BIN Number
PCN Number
Group Number
ID Number
Insured Patients
I authorize the pharmacy to bill my insurance on my behalf for the immunization.
Uninsured Patients
I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan.
Screening for Immunization
Has the person to be vaccinated received a flu vaccine before?
*
Yes
No
Does the person to be vaccinated have an allergy to eggs, egg products, latex, or to a component of the vaccine?
*
Yes
No
Has the person to be vaccinated ever had a serious reaction to the influenza vaccine in the past?
*
Yes
No
Is the person to be vaccinated currently pregnant, breastfeeding, or planning to become pregnant in the next 30 days?
*
Yes
No
Is the person to be vaccinated allergic to thimerosal or mercury derivative preservatives?
*
Yes
No
Does the person to be vaccinated have an active infection, illness, or fever today?
*
Yes
No
Does the person to be vaccinated have uncontrolled seizures or an active neurologic disorder?
*
Yes
No
Does the person being vaccinated take blood thinners, such as Coumadin, Warfarin, Plavix, Xarelto, Eliquis, etc?
*
Yes
No
Is the person to be vaccinated taking an antibiotic at this time?
*
Yes
No
Has the person to be vaccinated ever had Guillain-Barre syndrome?
*
Yes
No
Consent for Immunization
I, undersigned, attest to the following:
*
I certify the information above is correct and accurate to the best of my knowledge.
I have been given a copy and have had explained, the information in the Vaccine Information Statement- "Influenza Vaccine- What you need to know" (dated 08/06/2021) regarding the vaccine I am receiving.
I have had the opportunity to ask questions and all my questions concerning the vaccine have been answered to my satisfaction.
I understand the benefits and risks of receiving the vaccine and request that it be given to me.
I understand my pharmacy will submit this immunization information to the state immunization registry (Florida SHOTS).
I hereby hold harmless Acquaviva's Pharmacy, Carl D. Acquaviva, and affiliated entities, their directors, trustees, employees, agents, and representatives from and against any and all liabilities, claims, costs, losses, damages, expenses, and attorney's fees, resulting from or attributable to receipt of the influenza vaccine.
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: