Claremont Colleges Flu Vaccine Consent

Vaccine Recipient Name*

First NameMiddle NameLast Name

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code

Email (to receive confirmation and informational documents)

example@example.com

Date of Birth*

Gender at birth*

Age

AGE

A parent or guardian must be present during the vaccine appointment for any patient under age 18.

	Check box
Check this box to indicate that a parent or guardian will be present during the entire vaccine appointment and will sign the consent form.

Race*

Required by California Department of Public Health

Ethnicity*

Required by California Department of Public Health

Vaccine Recipient Phone Number*

Mother's First Name*

Required for proper vaccine documentation

Primary Care Provider Name

If you would like to have a copy of this record sent to your Primary Care Provider, please provide the name here.

Influenza Vaccine Screening Questions (If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional information may be necessary before vaccination.)

	Yes	No
1. Are you allergic to eggs or any component of the influenza vaccine?
2. Have you ever had a serious reaction to the influenza vaccine?
3. Have you had Guillain-Barre Syndrone, a condition that causes paralysis?
4. Are you pregnant or planning to become pregnant n the next 3 months?

Consent (check each box below after reading and prior to signing the form)*

	Check each box
I agree to stay in the vaccine administration area if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I acknowledge that my immunization information from this visit will be sent to the California Immunization Registry unless I choose to opt out.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hendricks Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).
I have read and reviewed the Notice of Privacy Practices available at www.HendricksPharmacy.com/NOPP.

Insurance (We are not able to bill Kaiser or some out of state or closed network plans)*

	Yes	No
Do you have health or medical insurance (examples include Medicare, Medi-Cal, or private health policies)? We are not able to bill Kaiser or some out of state or closed network plans. You are welcome to pay out of pocket for the vaccine if your insurance will not cover the cost.

Type of insurance

Please select the type of prescription insurance that you have. (We can't bill Kaiser or some out of state or closed network plans.)

Sorry, we can't bill Kaiser insurance. If you would like to get a vaccine and pay out of pocket, please change your response to no insurance and submit.

Sorry, we are only able to bill vaccine to Medi-Cal for adults age 19 and older. You will need to find a provider enrolled in the Vaccine For Children (VFC) Program.

Insurance ID#

Please enter the ID# from your insurance card (Medicare, Medi-Cal, or Private/Other).

The Flu vaccine is available no matter if insured or uninsured. Since you indicated you have insurance, please read and check this box.

	Check box
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you may be responsible for the cost, or a portion of the cost, of the vaccine and its administration should your insurance not fully cover it.

The Flu vaccine is available no matter if insured or uninsured. Since you indicated you do not have insurance, please read and check this box.

	Check box
If UNINSURED, you must check this box to attest that you understand that you will be charged for the vaccine upon arrival to your appointment.

Full Name

CurrentDate

Date

Flu Vaccine Preregistration Consent - Claremont Colleges