Flu Pod Pre-Registration Form 2025

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip

Phone*

Date of Birth*

Date

Sex*

Mother's Maiden Name*

Do you have any health conditions such as: heart disease, diabetes, or asthma?*

Don't KnowNoYes, please indicate

Do you have allergies to latex, medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, or thimerosal) If yes, please list:*

Don't KnowNoYes, please indicate

Have you received any vaccinations or skin tests in past four weeks? If yes, please list:*

Don't KnowNoYes, please indicate

Have you ever had a reaction after receiving an immunization, including fainting or feeling?*

Don't KnowNoYes

Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré Syndrome (a condition that causes paralysis) or other nervous system problem?*

Don't KnowNoYes

Women Only: Are you pregnant or considering becoming pregnant in the next month?

Don't KnowNoYes

I certify that I am: (a) the patient and at least 18 years of age; (b) the parent of legal guardian or the minor patient; or (c) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider* of Cibola General Hospital, as applicable, to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and received, read/had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the health provider. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Cibola General Hospital, as applicable, its staff, agents, successors, divisions, affiliates, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown, arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that (a) I understand the purpose/benefits of my state’s immunization registry; (b) I may, if my state permits, object to Cibola General Hospital disclosing my immunization information to the registry with a signed opt-out form. I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed opt-out form. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my immunization information to or through the state health information exchange as required or permitted by law. I also authorize the applicable Provider to disclose my, or my child’s (or unemancipated minor for whom I am authorized to act as guardian or loco parentis) proof of immunization to the school where I am, or my child is a student or prospective student. I further authorize Cibola General Hospital to (a) submit a claim to my insurer for the above requested items and services, and (b) request payment of authorized benefits be made on my behalf to Cibola General Hospital with respect to the above requested items and services. I further agree to be fully financially responsible for any cost sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible at the time of service or, if Cibola General Hospital invoices me after the time of service, upon receipt of such invoice.

A signature/date will be captured the day of the event for adults and parents/guardians of children.

INSURANCE INFORMATION (Insurance reimbursement provides us the ability to continue to provide the vaccine, supplies, and volunteers for the event)

Name of Insured

Relationship to Insured

Insurance Company

Group

Identification Number

Vaccine Administration Record (VAR)