2022 Flu COVID Demographic Sheet

Influenza and COVID-19 Vaccine
Last
First
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyy
Gender
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Ethnicity
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Allergies
Race
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Provider
Maiden/Other Names
Minor's Father
Minor's Mother
What vaccines are you wanting today? (Check all that apply)

Answer the questions in regards to the person receiving services today. Any YES answers will be discussed

Rows	Yes	No
Is patient sick today, with a fever?
Does patient have an allergy to eggs or to a component of the influenza vaccine?
Has patient ever had an allergic reaction to any other vaccine or an injectable medication? (This would include severe allergic reaction i.e., anaphylaxis that requireds treatment with epinepherine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing)
Has patient ever had Guillian-Barre syndrome?
Has patient received any other vaccinations in the past 4 weeks?
Is patient immunocomprised or around someone who is? (This would include, but not limited to, treatment for cancer, HIV, receipt of organ transplant, immunisuppressive therapy or high-dose corticosteriods, CAR-T-cell therapy, hematopoietic cell trans plant {HCT}, or moderate or sever primary immunodeficiency)
Is the patient pregnant or could become pregnant within the nexxt month?
Is patient a household contact of infant?
Has the patient ever felt dizzy or faint before, during or after shot?
Is the patient aged 3-64 years old who is at higher risk for influenza-related complications (for the vaccine-preventable disease(s).

Insurance Information: Would you like to take a photo or type your info:
Take a photo of the front & back of your insurance card(s)

Cancelof
Insurance Carrier
Name of Insurance company
Group #
Policy #
Subscriber name (if spouse or parent)
Name of person insurance is under
Subscriber Date of Birth (if parent or spouse)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have read the Vaccine Information Sheet(s) and have had a chance to ask questions. The risks and benefits have been explained to me. My signature below indicates that I consent to the vaccine(s) to be given to me or the person named above for whom I am authorized to make this request. I give this consent without coercion or reservation.

Assignment of Benefits: All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. The patient/parent/responsible party is responsible for any unpaid balances. Co-payments will be made at the time of service. I request that payment of authorized Medicare, Medicaid or Other insurance company benefits be made to HCHD for any services furnished to me by HCHD. Regulations pertaining to Medicare and Medicaid assignment of both benefits apply. My signature indicates all information provided is true and correct.
Consent for Inclusion in MT's Statewide Immunization Information System (IIS): I authorize HCHD to collect and enter my or my child's immunization records into the Department of Public Health and Human Services' IIS. The IIS is a confidential, computer system that contains immunization records. I understand that information in the registry may be released to the public health agency as well as my or my child's health care providers to assist in my or my child's medical care and treatment. In addition, information may be released to child care facilities and schools in which my child is enrolled to comply with state immunization requirements. I understand that I can revoke this authorization and have my or my child's record removed at any time by contacting my local health department.
Signature
Should be Empty: