Flu shot clinic

Name of individual receiving the vaccination:

First NameLast Name

DOB:

Date

AGE:

Parent/Guardian name (if applicable, if not put N/A):

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Billing Address

Mailing address

CityState

Zip Code

For information on the vaccines below, you can visit http://immunize.org/vis or call our office at 406-932-5449.

Please check which vaccine you would like for you or your child to receive.

State provided Vaccine (VFC- Vaccines For Children) is available, at little or no cost, to those who qualify.

Please check the appropriate statement.

Please indicate if you fit into one or more of the groups below: (check all that apply)

Insurance Information (Enter N/A if no insurance)

Insurance Company (BCBS, Medicaid, EBMS, etc.)

Member ID #

Group #Policy Holder (as read on card)

Policy Holder DOB

Which clinic will you be attending?

Are you sick today? (If this changes on day of vaccination, please let us know).

Have you had a serious reaction to a vaccine in the past?

Do you have a history of Guillain-Barre Syndrome?

**FLUMIST ONLY QUESTIONS(select all that apply):

If you answered yes to any of the above questions, please explain here:

Terms & Conditions

Consent to Treat: I authorize Sweet Grass County Health Department (SGCHD) to administer treatment as deemed necessary for the care of the patient named above. I certify that I am the parent or legal guardian of the patient. I also certify that no guarantee or assurance has been made as to the results that may be obtained from the treatment.

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 Medicare, Medicaid and other insurance company benefits be made to SGCHD for any services furnished to me by SGCHD. Regulations pertaining to Medicare and Medicaid assignment of both benefits apply. My signature indicates all information provided is true and correct.

Consent for Imclusion in MT's Statewide Immunization Information System (IIS): I authorize SGCHD 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.

Do you consent for yourself/your child to receive the vaccine selected and agree to the terms and conditions?

Signature(parents must sign for anyone under the age of 18):

Today's Date:

Date

Sweet Grass Public Health Flu shot Clinic Registration