Beyfortus Injection Assessment

Name of Patient*

First Last

Date of Birth*

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 I am paying $650 today 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.

I am aware that I may receive a credit should my insurance FULLY cover the cost of the Beyfortus (nirsevimab) injection.*

I agree.

It is my sole responsibility to confirm coverage and payment details with my insurance provider. There is no guarantee that my insurance company will cover and/or pay for the cost of the Beyfortus (nirsevimab) injection, even if initially indicated.*

I agree.

I understand Pediatric People PLLC makes no assurances regarding insurance coverage or payment for the Beyfortus (nirsevimab) injection.*

I agree.

I understand that Pediatric People is not responsible for contacting my insurance provider concerning the coverage or payment for the Beyfortus (nirsevimab) injection. Pediatric People, PLLC will submit a claim to my insurance company.*

I agree.

I understand that this sale is FINAL and there are NO REFUNDS after my credit card is charged.*

I agree.

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

Yes

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

Yes

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

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?*

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?*

Yes

Parent or Legal Guardian*

First Last

Relationship to Patient*

Signature of Parent or Legal Guardian*

Beyfortus Injection

Price:

Total

Cardholder Agreement
I authorize Pediatric People, PLLC to to charge my credit card below in the amount of $550.00 for the Beyfortus (nirsevimab) Injection. I understand and agree that this sale is FINAL and there are NO REFUNDS after my credit card has been charged.

Payment Method*

BEYFORTUS INJECTION ASSESSMENT