Don Quijote Influenza Consent Form 2025-2026

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
2 digit month, 2 digit day, 4 digit yearDate
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.)
Phone Number
Format: (000) 000-0000.

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?
Medicare Part B ID#
(example format: 1EG4-TE5-MK72)
Medical Insurance Coverage?
Relationship to Subscriber
Primary Insurance Plan Name
(example: HMSA, Kaiser, UHA, etc)
Membership or Subscriber ID#
Subscriber's Name
Subscriber's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
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
Military Sponsor's SSN or DBN (If covered by DOD Benefits

Rows	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