Influenza Vaccine Agreement

This field is hidden when viewing the form

Show Calendar

Yes

Is the person being vaccinated a new patient?*

Yes

Please select an appointment date and time:*

A health questionnaire MUST be completed for EACH patient being vaccinated.*

I agree.

Patient 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

1. Does the person to be vaccinated have an allergy to eggs or to a component of the influenza vaccine?*

YES

2. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?*

YES

3. Has the person to be vaccinated ever had Guillain-Barré syndrome?*

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?*

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?*

YES

6. Has a healthcare provider told you that you’ve had wheezing or asthma?*

YES

7. Is the person to be vaccinated sick today?*

YES

8. Has the person to be vaccinated taken the antiviral medications, Tamiflu, Relenza, Amantadine or Rimantadine within the past two weeks?*

YES

9. Is the person to be vaccinated receiving aspirin therapy or aspirin-containing therapy?*

YES

10. Is the person to be vaccinated pregnant or could she become pregnant within the next month?*

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)?*

YES

12. Has the person to be vaccinated received IV IGG the past year?*

YES

13. Has the person to be vaccinated received the Shingles, MMR, MMRV or Varicella vaccine in the past 4 weeks?*

YES

Is the person to be vaccinated allergic to any medications?*

YES

What medications?*

Does the person to be vaccinated take any medications?*

YES

What medications?*

Medication Name

Reason

Do you have any chronic medical conditions?*

YES

Please list your chronic medical conditions.*

Have you ever been hospitalized?*

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*

INFLUENZA VACCINE