Patient Registration Form
For Village of Logan Employees Only
Name
*
First Name
Last Name
Insurance Information
*
Insurance
Identification Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Date
Social Security Number
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Gender
*
Please Select
Male
Female
Age
*
Please check which tests are to be performed
*
Complete Lab Profile (CBC, CMP, Lipid Panel, TSH, Free T4, HGB A1C, Vitamin D, PSA Screening for Men Only)
EKG (Electrocardiogram)
Height/Weight
Body Fat Analysis
Blood Pressure
Flu Vaccine
Received Influenza Vaccination at Another Facility
Name of facility/clinic or physician's office where I received the flu vaccine:
Contraindication (see below) the influenza vaccine should not be taken by certain individuals. Please check any that apply.
Have you ever experienced allergic reaction to chicken eggs, chicken feathers or chicken dander?
Have you ever had an allergic reaction to a flu vaccine?
Have you ever been allergic to Thimerosal, a mercery derivative?
Are you presently having symptoms of acute fever?
Are you now experiencing any acute and/or changing neurological disorders such as seizures?
Do you have a history of Guillain-Barre Syndrome?
Do you have any sensitivity/allergies to dry natural latex ruber?
I have read the contraindication and DO not have any.
If you have answered yes to any of the contraindications, the vaccine will not be administered until you receive a physician's approval.
Signature
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