PENDER COUNTY SCHOOLS - Staff Flu Form

FLU FORM
Pender County Health Department
803 S. Walker Street, Burgaw, NC 28425
910-259-1230
YOU MUST COMPLETE ALL FIELDS BELOW:

Information collected on this form will be used to document authorization for receipt of vaccine
School Name:*
Patients Name: (Last, First)*

Last NameFirst Name
Social Security Number:*
Date of Birth: (mm/dd/yyyy)*

MonthDayYear
Date
Gender:*

MaleFemale
Ethnicity:*

HispanicNon-Hispanic
Race:*

WhiteAsianBlack or African-AmericanAmerican Indian or Alaskan NativeNative Hawaiian or Other Pacific Islander
Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Home Telephone Number:*
Please enter a valid phone number.
Work Telephone Number:
Please enter a valid phone number.
Health Insurance:*

MedicareMedicaidPrivateNone
Insurance Name: (If you do not have insurance, please put NA)*
Insurance Number: (If you do not have insurance, please put NA)*
Insurance Group Number: (If you do not have insurance, please put NA)*
Emergency Contact Name: (First, Last)*
Emergency Contact Telephone Number: *
Please enter a valid phone number.
Emergency Contact Relationship*
MINORS ONLY: Mothers Maiden Name: (Last, First, Middle Initial)
PLEASE ANSWER ALL OF THE FOLLOWING:
1. Are you currently pregnant?*

YesNo
2. Have you ever experienced Guillain-Barre Syndrome after receiving a flu vaccine or have a history of Guillain-Barre Syndrome?*

YesNo
3. Have you ever had a reaction to a previous dose of Flu vaccine?*

YesNo
I certify that I am: (a) the patient and at least 18 years of age: (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where the patient is not otherwise competent or unable to consent for themselves. (d) an unaccompanied minor consenting for preventative vaccines as allowed by North Carolina state law.

I have read, or had explained to me, the Vaccine Information Statement(s) for the recommended or required vaccine(s) checked above. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccines as described. I request that the vaccine(s) be given to me (or the person named above for whom I am authorized to make this request).

Vaccine Information Statement Link
Signature *

Clear
Date Signed:*

MonthDayYear
Date
Should be Empty:

YOU MUST COMPLETE ALL FIELDS BELOW: