2025-26 General Flu & COVID Consent Form

2025-2026 Flu & COVID Vaccine Consent

Warren County Health Services
Name:*

First NameLast Name
Birthdate:*

MonthDayYear
Date
Gender:

MaleFemalePrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Pacific IslanderPrefer not to answerOther
Ethnicity:*

Hispanic or LatinoNon-Hispanic or LatinoUnknownPrefer not to answer
Phone Number*
Please enter a valid phone number we can reach you at if we have any questions.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which vaccine are you wanting?

Flu ShotFlu MistCOVIDOther
How do you qualify for a COVID vaccine?

Over age 65Age 6 months- 64 years, at least one underlying high-risk medical condition
Appointment
Insurance Information
Do the person to be vaccinated have insurance that covers vaccines?*

YesNoI don't know
Please upload the front and back of your insurance card, or enter the appropriate card information below. If you have insurance questions, please call us at 515-690-9190.
Vaccines for Children (VFC) Program Eligibility:*

Enrolled in MedicaidDoes not have health insuranceis American Indian or Alaskan Native (AI/AN)Underinsured (has health insurance that DOES NOT pay for vaccinations)Not VFC eligible; my child has health insurance that covers the cost of vaccines
Please upload the front of insurance card

Cancelof
Please upload the back of insurance card

Cancelof
Insurance Company:
Ex: Wellmark, United Healthcare
Member ID:
Group #:
Card Holder Name:*
Card Holder DOB:*
Relationship to Patient:*
Screening Checklist for Contraindications to Injectable Influenza Vaccine

For patients to be vaccinated (both adults and children): The following questions will help us determine if there is any contraindications to vaccination today. If you answer "Yes" to any question, it does not necessarily mean your child should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

	Yes	No	Unsure
Is the person being vaccinated sick today or have a fever?
Does the person being vaccinated have an allergy to an ingredient of the vaccine?
Has the person being vaccinated ever had a serious reaction to influenza vaccine in the past?
Has the person being vaccinated ever had Guillain-Barre Syndrome?
Is the person to be vaccinated anxious about getting a shot today?
Has the person to be vaccinated ever felt dizzy or faint before, during, or after a shot?

Please answer the additional questions below ONLY if receiving the Flu Mist (ages 2-49)

	Yes	No	Unsure
Is the person to be vaccinated younger than age 2 years or older than age 49?
If the person to be vaccinated is a child between 2 and 4 years, in the past 12 months has a healthcare provider told you the child has wheezing or asthma?
Does the person to be vaccinated have a long-term health problem with heart disease, lung disease (including asthma), kidney disease, neurologic disease, liver disease, or metabolic disease (diabetes)?
Does the person to be vaccinated have a) an open channel between the cerebrospinal fluid (CSF) and the mouth, throat, nose, or ear or any other cranial CSF leak, or b) a cochlear implant, or c) an immunocompromising condition due to any cause (medication, congenital or acquired immunodeficiency, HIV infection, or a missing or non-functioning spleen [eg: caused by sickle cell disease])?
Is the person to be vaccinated currently taking influenza antiviral medications, or have they taken any within the last 3 weeks?
Is the person to be vaccinated currently pregnant, or could become pregnant in the next month?
Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is compromised and who must be in protective isolation (eg: an isolation room of a bone marrow transplant unit)?
Has the person to be vaccinated received any other vaccines in the past 4 weeks?

Consent for Vaccination:

I have read, or have had explained to me, the information about the vaccine(s) being administered today. I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of vaccination and request vaccination to be administered to me, or the above named for whom I am authorized to make this request.

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain right to privacy regarding my protected health information. The Notice of Privacy Practice has been made available to me, which explains these rights. Warren County Health Services Notice of Privacy Practice can be viewed online at: https://healthservices.warrencountyia.org/Policy_HIPAA.pdf

I authorize the release of medical or other information necessary to process billing claims. I authorize Payer to pay provider directly and agree to pay any co-pay, deductible, or amount not paid by insurance.
Form completed by*

First NameLast Name
Signature of Patient (or Parent/Guardian of person less than 18 years old)*

Clear
Patient is person receiving immunization
Should be Empty:

2025-2026 Flu & COVID Vaccine Consent

Insurance Information

Screening Checklist for Contraindications to Injectable Influenza Vaccine