(STORE) Influenza Consent Form 2023-2024

Influenza Vaccine

Consent & Release Form
Section 1 of 3 - Recipient Information

All 3 sections are required for each vaccine recipient. All information is protected under HIPAA privacy laws.
Recipient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
NOW

MonthDayYear
Date
Age
Gender*

MaleFemale
Phone Number*

Area CodePhone Number
Preferred Contact Email*

Confirmation EmailPlease enter email address twice to verify. We will send important information and required documents via email.
Address*

Street Address

CityState

Zip Code
PHYSICIAN (M.D) INFORMATION

Please provide your Primary Care Physician's information
Primary Care Physician's Name

First NameLast Name
M.D Office Location
(Ex. Straub, Queens, Kaiser, etc.)

Section 2 of 3 - Insurance Information

If you have medical coverage please provide the information below.
Last 4 digits of Social Security
(required for ages 65+)
Do you have Medicare Part B?*

YesNo
Medical Insurance Coverage?*

Yes, I have coverageNo, I do not have insurance coverage
Medicare Part B ID#
(example format: 1EG4-TE5-MK72)
Relationship to Subscriber*

SelfSpouseDependent
Primary Insurance Plan Name*
(example: HMSA, Kaiser, UHA, etc)
Membership or Subscriber ID#
Military Sponsor's SSN or DBN (If covered by DOD Benefits
Subscriber's Name*
Subscriber's Date of Birth*

MonthDayYear
If applicable on insurance card, please provide your:
- Rx BIN Number
- Rx PCN Number
- Rx GROUP Number
Rx BIN Number
6 digit number
Rx PCN Number
Rx GROUP Number

	YES	NO	DON'T KNOW
1. Have you received a flu shot in the past 6 months?
2. Do you have allergies to medication, food, a vaccine component, or latex?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have a history of Guillain-Barre syndrome? (severe temporary muscle weakness)
5. Any history of fainting?

Section 1 of 3 - Recipient Information