Beyfortus Injection Agreement – Pediatric People

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Beyfortus Injection AgreementMichael2024-11-05T13:27:12-06:00

BEYFORTUS INJECTION AGREEMENT

"*" indicates required fields

Name of Patient*

First Last

Date of Birth*

MM

DD

YYYY

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Age Verification

We can only administer the Beyfortus vaccine to patients between 1 week and 2 years of age.

I am aware that we will monitor the patient in the office for 30 minutes after administration of Beyfortus*

I agree.

I acknowledge that If my insurance does not cover this visit I will be responsible for making a payment of $650 for my child's Beyfortus (nirsevimab) injection.*

I agree.

I understand that appointments canceled less than 24 hours before the scheduled start time — or missed without prior notice — will incur a $300 fee.*

I agree.

Does the patient have a known history of bleeding or bruising problems?*

No

Yes

Did the patients mother receive the maternal RSV vaccination Abrysvo during pregnancy?*

No

Yes

Was it administered 2 weeks or more prior to delivery of the infant?*

No

Yes

Beyfortus is not typically recommended for infants if the mother received the RSV vaccination 2 weeks or more prior to delivery.

Did the patient receive Beyfortus in the previous RSV season?*

No

Yes

What day was it administered?

Month

Day

Year

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Day Calculation

Beyfortus must be administered at least 150 days apart

Did the patient have a serious allergic reaction to Beyfortus?*

No

Yes

Parent or Legal Guardian*

First Last

Relationship to Patient*

Signature of Parent or Legal Guardian*