Vaccine Consent Form

Vaccine Consent Form

* Please fill out the required details below
Which Vaccine are you wanting to get?
Todays Date*

MonthDayYear
Date
Form Completed by:*
Please type your name
NOTE* Warren County Health Services currently offers Private insurance vaccines for Menningitis B, Hep B, Hep A, HPV, Menningitis, PCV20, Tdap, Shingrix.

We offer also Covid, Flu and RSV during respiratory virus season.
Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Phone Number:*
Email:*
Social Security:*
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
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))
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 required.

If you are privately insured, please upload your insurance card and we can see what vaccines are covered for you.

If you have insurance questions, please call us at 515-690-9190.
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

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Healthcare Insurance Information:
Medicaid, Medicare, or MCO Number:
Enrolled Company:
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 vaccinate today. If you answer “yes” to any question, it does not necessarily mean you 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, 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
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
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
Appointment*
Is the person to be vaccinated pregnant or could become pregnant within the next month?

YesNoDon't Know
I have read, or have had explained to me, the information about this vaccine. I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of 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 abides by the HIPPA Notice of Privacy Practice which can be viewed online at https://www.cdc.gov/phlp/publications/topic/hipaa.html.

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.

By providing my signature, I consent to these terms and my signature represents agreement with the following documents: • Notice of Privacy Practices (NPP) Acknowledgment. • Consent for Treatment and Authorization.
Signature of Person/Parent/Guardian Receive Vaccine *

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Form Reviewed by WCHS Staff:
Date
Should be Empty: