Influenza vaccine permission 2001-2002

WESTPORT WESTON HEALTH DISTRICT
Received by:
INFLUENZA VACCINE PERMISSION
PRINT CLEARLY
________________________________________________ ________________ Age ______  Male Female
Patient’s Name as it appears on your Insurance card
Date of Birth
________________________________________________________________
(_____)_________________

Last 4 digits of your SS# ____________________ Method of payment:  Cash _____  Check#_______
PROVIDE a copy of your Insurance card: Medicare B Aetna Anthem BC Cigna ConnectiCare
Name of Primary Card Holder: _________________________________ Date of Birth : _______________

Have you ever had a flu vaccination? …………………………………………….  Yes  No
Have you ever had a serious reaction from a previous flu vaccination? .….  Yes  No
Are you sick or do you have a fever today? …………………………………….  Yes  No
Are you severely allergic to eggs, gentamicin, gelatin, argine or latex? ……  Yes  No
Are you allergic to thimerosal (mercury-derived preservative)? …………….  Yes  No
Do you have/ had Guillain-Barre Disease? …………………………………….  Yes  No
FOR FLU MIST ONLY: Please answer the questions below:
If you are younger than 5 years, have you had one or more episodes of wheezing in the past year?. Yes  No
Do you have asthma or lung disease? …………………………………………………………………
 Yes  No
Do you have Diabetes, heart, liver, kidney, blood, or neurological disorder?. Yes  No
Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune
system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or
drugs? ………………………………………………………………………….………  Yes  No
Have you received any other vaccinations in the past 4 weeks? ……………  Yes  No
Are you pregnant or nursing? ………………………………………………………  Yes  No
Have you received any antivirals (i.e., Amantadine, Tamiflu, Relenza) in the past 48 hours?  Yes  No
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I have read, or had explained to me, the information sheet about the Influenza Vaccine. I have had a chance to ask questions which
were answered to my satisfaction and I understand the benefits and risks of the vaccination. I request that the vaccine be given to me
(or the person named below, for whom I am authorized to make this request).
Health information may be disclosed for the following purposes: a) to bill and receive payment for the flu vaccine you have received;
and/or b) to report any adverse reaction you may experience after receiving the flu vaccine. I authorize release of any medical or other
information necessary to process an insurance claim. I understand that if the insurance rejects payment for this vaccination that
the health district will bill me and I agree to pay the fee.

___________________________________________________
Signature of Recipient (or Parent or Guardian) FOR CLINIC USE ONLY

Clinic Site: ________________________________
Date Vaccinated: ___________________________

Manufacturer & Lot Number: ______________________________________ Exp. Date: _____________
Injection Site:  Left Arm  Right Arm
Dosage (circle one): 0.25cc OR 0.5cc OR 0.2ml Intra-nasal OR High Dose
Vaccinator’s Signature: ________________________________________________
INFLUENZA VACCINE PERMISSION 2013-14 (2).doc

Source: http://wwhd.org/downloads/fluform2013.pdf