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Influenza Vaccine Agreement
Michael
2023-07-03T17:05:06-05:00
INFLUENZA VACCINE
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Is the person being vaccinated a new patient?
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Yes
No
Please select an appointment date and time:
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A health questionnaire MUST be completed for EACH patient being vaccinated.
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I agree.
Name
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Last
Gender
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Female
Date of Birth
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Age
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Select Age
6 Months
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1 Year
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Phone
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Email
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Enter Email
Confirm Email
Payment Method
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Insurance
Self Pay
How would you like to send us a photo of your drivers license.
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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
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Max. file size: 512 MB.
How would you like to send us a photo of the front and back of your insurance card.
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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
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Max. file size: 512 MB.
Photo Upload - Back of Insurance Card
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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?
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NO
YES
2. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
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NO
YES
3. Has the person to be vaccinated ever had Guillain-Barré syndrome?
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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?
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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?
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NO
YES
6. Has a healthcare provider told you that you’ve had wheezing or asthma?
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NO
YES
7. Is the person to be vaccinated sick today?
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NO
YES
8. Has the person to be vaccinated taken the antiviral medications, Tamiflu, Relenza, Amantadine or Rimantadine within the past two weeks?
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NO
YES
9. Is the person to be vaccinated receiving aspirin therapy or aspirin-containing therapy?
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NO
YES
10. Is the person to be vaccinated pregnant or could she become pregnant within the next month?
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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)?
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NO
YES
12. Has the person to be vaccinated received IV IGG the past year?
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NO
YES
13. Has the person to be vaccinated received the Shingles, MMR, MMRV or Varicella vaccine in the past 4 weeks?
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NO
YES
Is the person to be vaccinated allergic to any medications?
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NO
YES
What medications?
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Add
Remove
Does the person to be vaccinated take any medications?
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NO
YES
What medications?
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Medication Name
Reason
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Remove
Do you have any chronic medical conditions?
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NO
YES
Please list your chronic medical conditions.
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Add
Remove
Have you ever been hospitalized?
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NO
YES
Please list your hospitalizations.
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Reason
Year
Add
Remove
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
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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
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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
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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
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