Drive Thru Consent Form (2026-2027) Flu & Covid

Drive Thru Consent Form

*Macon County Health Department Flu & COVID-19 Vaccines 2026
Patient Information
Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Age
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Race

Other
Ethnicity
Please select which town you plan to visit our drive thru clinic at.

Vaccine History

Rows	Yes	No	If Yes, Please Explain
Are you feeling sick today?
Do you have allergies to any food, medications, or vaccine components? (egg, PEG, polysorbate)
Do you have any immune system problems or a bleeding disorder? Taking a blood thinner?
Have you ever been told you have Guillan Barre or MIS-A? (muscle weakness, paralysis)(multi-system inflammatory system)
Have you ever experienced a problem in the past after receiving a flu or COVID-19 vaccine?
Are you age 64 or younger with underlying health conditions? (diabetes, asthma, COPD, heart or kidney failure, high blood pressure, liver disease, blood disorders, neurologic or neuromuscular conditions, stroke, obesity, organ or stem cell transplant, cancer)

Please note about egg allergy and influenza vaccines: ACIP and CDC no longer consider egg allergy of any severity to be a contraindication or precaution to egg-based influenza vaccines. A person with egg allergy of any severity may receive any influenza vaccine that is appropriate for the person’s age and health status. When administering an egg-based influenza vaccine to a person with egg allergy of any severity, no additional safety precautions are needed, beyond those recommended when administering any vaccine to any recipient.
For more details about giving influenza vaccine to people with a history of egg allergy, go to www.cdc.gov/acip-recs/hcp/vaccine-specific/flu.html for a link to the current ACIP recommendations for influenza vaccination.
Please select which vaccine(s) you are planning to receive at the drive thru. (Flu & COVID-19 are separate shots)
Insurance Company Name (please put NONE if no insurance)
Insurance ID # / Medicare #
Insurance Group Number (if applicable)
Insurance Policy Holder's Name
Insurance Card: please upload front and back of card!

Cancelof
Additional Insurance (Medicare Adv. plans, secondaries) name & ID #
Secondary Insurance Card: Please upload front and back of cards!

Cancelof
Please review vaccine information statements for Flu & Covid-19 vaccines at the links below, as well as the HIPAA privacy act.

FLU: https://www.immunize.org/wp-content/uploads/vis/flu_inactive.pdf

COVID-19: https://www.immunize.org/wp-content/uploads/vis/covid-19.pdf

HIPAA: https://health.mo.gov/about-dhss/notice-privacy-practices
This record will be kept on file at the Macon Co. Health Dept. It will include when the vaccine was given, the name of the vaccine manufacturer, lot number, and injection site. I have read and been offered a copy of the Vaccine Information Statement and have had the opportunity to ask questions and had them answered to my satisfaction. I understand the benefits of receiving the vaccine(s) and give my consent to receive the injection(s). I give consent for my insurance (if applicable) to be billed, and if denied, I understand that I am responsible for the payment in full. By signing below, I acknowledge that I have been offered a copy and/or read the HIPAA Privacy Act and agree to the statements above.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Drive Thru Consent Form

Patient Information