Putnam Co. R-1 School Influenza Vaccine Consent Form
Provided by: Putnam County Health Department
Child Information
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Address
*
Street Address
Street Address 2
City
State
Postal / Zip Code
Teacher's Name (elementary only)
First Name
Last Name
Insurance
Please select one of the below.
*
My child has MO HealthNet or insurance provided through the State of MO.
My child has privately paid health insurance through the Marketplace, work, etc.
My child has no health insurance.
My child is a American Indian/Alaskan Native.
Please enter your child's MO HealthNet number below, if applicable.
Health History
Vaccine Screening
*
Yes
No
If Yes, Please Explain
Does your child have a serious egg allergy?
Has your child ever had a serious reaction to any previous flu vaccine?
Has your child ever been diagnosed with Guillain-Barre Syndrome (a type of severe muscle weakness)?
Is your child ill today?
Does your child have any serious allergies to medication, food (eggs), vaccines or latex?
Is your child pregnant or could become pregnant in the next 30 days?
Is your child on antiviral or antibiotics?
If your child is under the age of 9, has your child received two doses of flu vaccine before July 2025?
Do you have any questions/concerns regarding the flu vaccine that you would like for a nurse to contact you about?
*
Yes, I have questions/concerns. Please contact me.
No, I have no questions/concerns.
2025-2026 Influenza Vaccine Information Statement - (Click
here
to read the VIS).
HIPAA Compliance Policy and Procedures
Acknowledgment of HIPAA Compliance
*
I acknowledge by my signature below, that I have been offered a copy of Putnam County Health Department’s “Notice of Privacy Practice Act (HIPAA)”. I understand that if my child has Medicaid, insurance will be billed for vaccine and injection.
Consent
Consent For Immunization
*
Yes, please vaccinate my child with the 2025-2026 seasonal influenza vaccine. I have read or been provided with the opportunity to read the 2025-2026 Influenza Vaccine Information Statement for the vaccine indicated above. I have had the opportunity to ask questions. I understand the benefits and risks of the vaccine requested and ask that the vaccine for which I have signed below, be given to the person indicated above. I am authorized by RSMo 431.058 to make this request.
Parent/Guardian Signature
*
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