• Flu Vaccines Screening,Consent and Administration Form

  • Please include a copy of your insurance card for billing purposes or email to inscard@mrhcia.com. Please fill out one form for each individual receiving the flu vaccine.

  • PATIENT INFORMATION

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Choose One*

  • PATIENT INSURANCE INFORMATION

  • Do you have insurance?
  • Policy Holder’s DOB
     - -
    2 digit month, 2 digit day, 4 digit year
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  • VACCINE DETAIL

  • Choose requested vaccine*
  • Location of vaccination*

  • SCREENING QUESTIONNAIRE

  • 1. Do you have allergies to latex, eggs or thimerosal (a preservative)?*
  • 2. Do you have moderate to severe acute illness today, with a fever?*
  • 3. Have you ever had a serious allergic reaction to the influenza vaccine?*
  • 4. Have you ever been in a coma or had prolonged seizures, not attributable to an  identifiable cause within 7 days of administration of a vaccine?
  • 5. Have you had Guillian Barre’ Syndrome (a problem with your nervous system)?*
  • 6. Do you have uncontrolled epilepsy or a brain problem?*
  • 7. Have you had progressive neurological disorder, such as uncontrolled epilepsy?*
  • 8. Have you had any other vaccines in the past 4 weeks?*
  • 9. Are you pregnant?*
  • 10. Do you have cancer, leukemia, AIDS, or any other immune system problem?*

  • CONSENT INFORMATION

  • If this vaccine is for a CHILD age 6 months to 18 years and is not covered by an Insurance named above:

  • I voluntarily consent and request that MRHC (submit or not submit) the claim for this service to my health insurance provider. I understand that full payment will be required now or after submission to health insurance provider. If I do not wish to have my insurance billed or my health coverage is inactive on the date of service, I agree to pay the $30 cash price per flu vaccine. I accept responsibility for seeking medical attention for any problems with this vaccine.*

  • Signature of person receiving the vaccine/patient representative:

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: