Immunize El Paso Influenza Vaccine Appointment

Influenza Vaccination Program

Immunization Consent and Appointment System

If you plan to vaccinate multiple members in your family, you MUST complete a submission for each person immunized.

If you will be using health insurance, please have a photo ID and insurance card ready before beginning. If you'd rather self-pay, you will need a major credit or debit card to complete the registration process.

Please have your ID and health insurance information on hand (if applicable), you will be asked to provide this information during registration.

If you experience difficulties, please contact 915-533-3414 (Mon-Fri 8A-5P)

Select Appointment Location & Time

Begin your appointment selection by choosing the Immunize El Paso location you'd like to visit.
Select Location
San Juan Clinic - 6292 Trowbridge, 79905
Eastside Clinic - 1400 George Dieter, Ste 225
Downtown Clinic - 513 W. San Antonio, Ste B 79901

Patient Registration
Who are you completing this form for? For children, a parent or guardian must complete this form.
Will you be attending the clinic with your child or dependent?
Patient Name

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Personal email address

Confirmation Emailexample@example.com
Race
Please describe your ethnicity
Parent, Guardian, Or Individual of Record

First NameMiddle NameLast Name
Texas Vaccines for Children(TVFC)Program Patient Eligibility

Health Insurance Information for Influenza

If you are insured, we ask for insurance information so Immunize El Paso can be reimbursed for the cost and administration of the vaccine through your insurance company. If your insurance is not listed below, we are unable to process claims through your insurance.
(Influenza)Health Insurance?
Select Your Insurance:
Patient Social Security Number
Member ID Number
Group Number
To whom is this policy issued:
Policy Holder Name

First NameLast Name
Policy Holder SSN
State/GVMT Issued ID

Browse Files

Cancelof
Photo of insurance card - FRONT

Browse Files

Cancelof
Photo of insurance card - BACK

Browse Files

Cancelof

Form Total
Private Cost
Stripe Cost Form Calculation
VFC Cost

Influenza Vaccine Payment

USDInfluenza Immunization

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Influenza Vaccination Consent
You are being given the opportunity to volunteer to participate in the seasonal Flu vaccinations, which may include needle injection. If you decide to participate in this vaccination process, please sign this form. You will be given a copy of this form to keep, upon request.

1. I agree that the person named above will get the inactivated influenza vaccine, the pneumococcal conjugate vaccine, and/or the pneumococcal polysaccharide vaccine.

2. I received or was offered a copy of the Vaccine Information Statement (VIS)

3. I know the risks of vaccine-preventable diseases.

4. I know the benefits and risks of the vaccine to be administered.

5. I have had a chance to ask questions about the diseases, the vaccine, and how the vaccine is given.

6. I know that the person named above will have a vaccine put in his/her body.

7. I am an adult who can legally consent for the person named below to get vaccines. I freely and voluntarily give my signed permission for each vaccine.

8. I authorize release of any medical or other information to process the claim. I also request payment of government benefits to the party who accepts assignment.

9. The patient (or patient’s guardian) is ultimately responsible for the payment for the treatment of care. We will bill your insurance on your behalf, however, you are required to provide the most current and updated insurance information. You are responsible for any applicable co-pays, deductibles & co-insurance payments associated with this vaccine administration.

I hereby certify that I have read and understand the information provided on this form. I have been given information about this vaccination process and its risks and benefits and have had the opportunity to ask questions and to have my questions answered to my satisfaction. I freely give my consent to receive this vaccination. I hereby release and hold harmless Immunize El Paso, ProAction, Inc, its, staff, employees, officers and directors, from liability, damage, or claim arising from any injury or complication that may result from receiving this vaccination.
Signature
Date Of Service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Influenza Vaccine Administered
Lot Number Influenza
Route & Site Influenza
Pneumonia Vaccine Administered
Lot Number Pneumonia
Route & Site Pneumonia
Given by
VIS Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date VIS Given

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Service
Should be Empty:

Rows	Yes	No
Are you currently under quarantine or isolation orders for COVID-19?
Do you have any COVID-19 or influenza-like symptoms? (Fever, cough, loss of sense of smell or taste, breath, sore throat, runny nose or congestion, nausea or vomiting, diarrhea)
Has a physician or medical provider indicated you should NOT receive the Influenza vaccine?
Have you ever had a serious reaction to a vaccine or a severe allergic reaction that required going to ER?
Are you allergic to egg?

Screening Questionnaire for Influenza Vaccination

Select Appointment Location & Time

Patient Registration

Health Insurance Information for Influenza

Influenza Vaccine Payment*

Influenza Vaccination Consent

Influenza Vaccine Payment