FLU CAPTURE

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This field is for validation purposes and should be left unchanged.
Are you a new patient?*
- Yes
- No

Name*
First Last
Date of Birth*
Month
Day
Year
Age*
Gender*
- Male
- Female
Phone*
Email*
Enter Email Confirm Email

Payment Method*
- Insurance
- Self Pay
How would you like to send us a photo of your drivers license.*
- Now
- Text Message
Please use your phone to take a photo of the following items and text them to 972-382-5796.
- Drivers License
Photo Upload - Drivers License*
Max. file size: 512 MB.
How would you like to send us a photo of the front and back of your insurance card.*
- Now
- Text Message
Please use your phone to take a photo of the following items and text them to 972-382-5796.
- Front of Insurance Card
- Back of Insurance Card
Photo Upload - Front of Insurance Card*
Max. file size: 512 MB.
Photo Upload - Back of Insurance Card*
Max. file size: 512 MB.
Influenza Vaccine*
Price:
Total
$0.00
Credit Card*
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1. Does the person to be vaccinated have an allergy to eggs or to a component of the influenza vaccine?*
- NO
- YES
2. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?*
- NO
- YES
3. Has the person to be vaccinated ever had Guillain-Barré syndrome?*
- NO
- YES
4. Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune system problem; or, in the past 3 months, have they taken medications that weaken the immune system, such as cortisone, prednisone, other steroids, or anticancer drugs; or have they had radiation treatments?*
- NO
- YES
5. Does the person to be vaccinated have a long-term health problem with heart disease, lung disease (including asthma), kidney disease, neurologic disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder?*
- NO
- YES
6. Has a healthcare provider told you that you’ve had wheezing or asthma?*
- NO
- YES
7. Is the person to be vaccinated sick today?*
- NO
- YES
8. Has the person to be vaccinated taken the antiviral medications, Tamiflu, Relenza, Amantadine or Rimantadine within the past two weeks?*
- NO
- YES
9. Is the person to be vaccinated receiving aspirin therapy or aspirin-containing therapy?*
- NO
- YES
10. Is the person to be vaccinated pregnant or could she become pregnant within the next month?*
- NO
- YES
11. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)?*
- NO
- YES
12. Has the person to be vaccinated received IV IGG the past year?*
- NO
- YES
13. Has the person to be vaccinated received the Shingles, MMR, MMRV or Varicella vaccine in the past 4 weeks?*
- NO
- YES
Is the person to be vaccinated allergic to any medications?*
- NO
- YES
What medications?*
Does the person to be vaccinated take any medications?*
- NO
- YES
What medications?*
Medication Name Reason
Do you have any chronic medical conditions?*
- NO
- YES
Please list your chronic medical conditions.*
Have you ever been hospitalized?*
- NO
- YES
Please list your hospitalizations.*
Reason Year

Based on age and/or answers to your health questionnaire, you are eligible to receive:
- FluMist
- Flu Shot
You cannot receive the flu vaccine. If you think this is an error, please contact us at 214-396-5200, ext 4.

Consent to Receive Influenza Vaccine*
I have read, understand and consent to receive the Influenza Vaccine.
There are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize influenza vaccine administration. I understand that this is a medical treatment and all medical treatments contain inherent risks. I have been offered a Vaccine Information Statement
Assignment of Benefits*
I have read, understand and agree to the Assignment of Benefits.
I hereby assign to Pediatric People PLLC all insurance benefits, if any, otherwise payable to me for services rendered to myself and/or my dependent(s), and I hereby authorize and direct my insurance carrier to issue payment of such benefits directly to Pediatric People PLLC. I authorize the use of my signature, and a copy thereof, on the insurance submissions
Notice of Privacy Practice*
I have read, understand and agree to the privacy practice.
I may receive a printed copy of this information upon verbal or written request now or in the future
Patient / Legal Guardian Signature*

Medication Name	Reason

Reason	Year