Drive Thru Flu/COVID Clinic - Saturday, 27th 2025

Full Name*

First NameMiddle InitialLast Name

Date of Birth*

Date

Gender*

MaleFemaleOther

Race:*

Ethnicity*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

What vaccine are you receiving?*

Influenza VaccineComirnaty (Pfizer) COVID Vaccine

1. Are you allergic to Gentamycin?*

YesNo

2. Are you allergic to gelatin?*

YesNo

3. Have you ever had a severe reaction to any vaccine in the past?*

YesNo

4.Do you have a history of Guillain-Barré Syndrome (GBS)?*

YesNo

5. Have you ever had any kind of motor-sensory neuropathy after a vaccine (for example numbness, tingling, or weakness)?*

YesNo

6. Are you allergic to eggs?*

YesNo

7. Are you allergic to latex?*

YesNo

Indicate if you fit into one or more of the groups:

Pregnant womanHousehold contact of infant less than 6 months oldPerson aged 3-64 years who is at higher risk of influenza-related complications (i.e., diabetes, cardiovascular or respiratory disease, immunosuppression)Adult over the age of 65 years

1. Have you ever had an anaphylactic reaction to any vaccine, medication, or other allergen in the past?

YesNo

2. Are you currently ill?

YesNo

3. Have you tested positive for COVID-19 in the past 3 months?

YesNo

4. Do you have a history of myocarditis or pericarditis?

YesNoN/A

5. Are you immunocompromised or receiving medications that suppress your immune system?

YesNo

6. If you answered yes to #1, #4, or #5, you have consulted with your provider and have decided to voluntarily receive the vaccine and are aware of the risks and benefits and are willing to accept the risks and continue.

YesNo

I fully understand and agree to the following:

•Consent to Treat: I authorize Butte-Silver Bow City-County Health Department to administer treatment as deemed necessary for care of the patient/client named above. If applicable, I certify that I am the parent or legal guardian of the patient/client. I also certify that no guarantee or assurance has been made as to the results that may be obtained from the treatment.

•Assignment of Benefits: I authorize payment of medical benefits to Butte-Silver Bow City-County Health Department for services rendered. I understand that the patient/parent or responsible party is responsible for any unpaid balances.

•ImMTrax State Immunization Registry: I understand Butte-Silver Bow Health Department may be required by law to report my administration information and basic data into the state immunization registry, a confidential computer system that contains immunization records. I understand that information in the registry may be released to local health departments, as well as my health care providers to assist in any medical care and treatment.

• (IF APPLICABLE) Emergency Use Authorization Form (EUA): I have received and reviewed the Emergency Use Authorization (EUA) Fact sheet plus any additional COVID-19 vaccine information and/or the Vaccine Information Sheet (VIS) that has been provided to me by the Butte-Silver Bow Health Department. I understand the listed potential risks and benefits of the vaccine and accept all risks.

•Vaccine Information Statement(s): I have read or have had explained to me the information contained in the Vaccine Information Statement(s) [VIS] about the disease(s) and the vaccines(s).

Signature*

Please upload the front of your insurance card:*

Front of Card

Please upload the back of your insurance card:*

Back of Card

Are you the policy holder of the insurance? If yes, type N/A. If not, please provide policy holder's name and date of birth. *

Check here if you don't have insurance or if your insurance doesn't cover vaccines

Drive Thru Flu/COVID Clinic - Saturday, 27th 2025

Vaccine Options:

Health Screening/Allergy Information:

Please only fill out if receiving Covid-19 Vaccine