Norwalk FLU Vaccine Consent

Norwalk FLU Vaccine Consent

* Please fill out the required details below
Which vaccine are you wanting to get?*

Flu InjectionFlu Mist
Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Form Completed by:*
Please type your name
Date*

MonthDayYear
Date
Phone Number:*
Email:*
Address:*

Street Address Line 2
Age*
Gender:*

MaleFemale
Child's Physician:
Mother's Full Name:*

First NameLast Name
Father's Full Name:*

First NameLast Name
Ethnicity?*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answerOTHER
Do you have insurance that covers vaccines?*

YesNoI don't know
Insurance Information

You may choose to upload the front and back of your insurance card, or enter the appropriate card information below. If you choose not insured, American Indian/Native Alaskan, or Underinsured, you child qualifies for VFC & no payment is reuqired, but donations are accepted. A $25 fee is invoiced if you do not have insurance or we are not able to bill your insurance. If you have insurance questions, please call us at 515-961-1074.
Indicate the person's eligibility status for Vaccine for Children Program (VFC) Program:

Is enrolled in Medicaiddoes not have health insuranceis American Indian or Alaskan Native (AI/AN)Underinsured (has health insurance that DOES NOT pay for vaccinations (can only receive VFC vaccine at Federally Qualified Health Center (FQHC), rural health clinic (RHC), or local public health(LPHA))
You may upload the front of your insurance card

Browse Files

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You may upload the back of your insurance card

Browse Files

Cancelof
Medicaid/MCO Number:
Enrolled Company:
Wellmark BC/BS or United Health Care Insurance Information
Member ID #
Group #
Card Holder Name:
Relationship to You:
Card Holder DOB:

MonthDayYear
Date
Questions

For patients to be vaccinated: The following questions will help us determine if there is any reason we should not give your child an inactivated injectable influenza vaccination today. If you answer “yes” to any question, it does not necessarily mean your child should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.
Is the person to be vaccinated sick today or do you have a fever?*

YesNoDon't Know
Has the person to be vaccinated ever had an allergic reaction (e.g. anaphylaxis) to any vaccines (including Flu & COVID-19), vaccine ingredients (e.g. Polyethylene Glycol, Polysorbate, eggs) or injectable medications in the past?*

YesNoDon't Know
Does the person to be vaccinated have any of the following? history of myocarditis or pericarditis or a diagnosis of that following a COVID-19 vaccine , any long-term health problem with heart disease, lung disease (including asthma), kidney disease, neurologic disease, guillain-barre syndrome, liver disease, metabolic disease (e.g. diabetes), anemia, or another blood disorder?*

YesNoDon't Know
Is the person to be vaccinated receiving influenza antiviral medications?*

YesNoDon't Know
Does the person to be vaccinated have a cochlear implant, spinal fluid leak, or no spleen; have cancer, leukemia, HIV/AID, or any other immune system problems, or, in the past 3 months, have they taken any medications that affect the immune system such as prednisone or other steroid drugs for the treatment of rheumatoid arthritis, receiving Aspirin-containing therapy, Crohn's disease, psoriasis or anticancer drugs or have they had radiation treatment?*

YesNoDon't Know
If the person to be vaccinated is a child age 2 thru 4, in the past 12 months has a Healthcare Provider told you the child was wheezing or has asthma?*

YesNoDon't Know
Is the person to be vaccinated pregnant or could become pregnant within the next month?*

YesNoDon't Know
Does the person to be vaccinated live with or expect to have close contact with a person with a severely compromised immune system who must be in protective isolation (e.g. isolation of a bone marrow transplant unit)?*

YesNoDon't Know
Has the person to be vaccinated received any other vaccination in the past 4 weeks?*

YesNoDon't Know
I have read, or have had explained to me, the information about influenza disease and the influenza vaccine. I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of influenza vaccination and request vaccination to be administered to me, or the above named for whom I am authorized to make this request.

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain right to privacy regarding my protected health information. The Notice of Privacy Practice has been made available to me, which explains these rights. Warren County Health Services Notice of Privacy Practice can be viewed online at: https://healthservices.warrencountyia.org/Policy_HIPAA.pdf . I authorize the release of medical or other information necessary to process billing claims. I authorize Payer to pay provider directly and agree to pay any co-pay, deductible, or amount not paid by insurance.
Signature of Parent/Guardian Receive Vaccine *

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Form Reviewed by WCHS Staff:
Date
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