Flu Clinic Parental Consent Form ln order for your child to obtain the influenza (Flu-Mist) vaccine during this schJol based clinic, you must:
□ 2.Sign&Date this form
E 1. Complete this form
キ:f uninsured we w‖ l
bill to address iisted below after client rece市
A. INFoRMATIoN eebur peRsoN Student's Name
REGETVTNG
□3.provide copy ofinsurance/Medicaid card* es vaccine.vaccine is S14.
vAcclrur (Pleasr pmrvr) Middle
Last
Student's Birth Date
Age
Gender Mole Femdle
Phone S
Relationship Studenfls Address
City
Zip Code
B.VACCINE FoR CHILDREN EttG:BILЛ Y SCREENINC(PLEASE CHECKAPPROPRIATE BOЮ □ Med:ca:d:A child,O thru 18 vears of agら whO has Mё dicaid coverage 口 American:nd:an′ Alaskan Natlve:A ch‖ d,o thru 18 years of age′
who iden■ les as an American lnd'an or Alaskan Natvq
regardless ofinsurance coverage □ No Health lnsurance:A cHld,O tlru 18years ofage,who does not have heanh hsurance □ Limited Health:nsurance:A child,O thru 18 years of agら who has health insurance but the health insurance does not pay for vacdnations{Please provide insurance card)
□ insured:A chi:d,O thru 18 years ofage,who has health:nsurance which provides coverage for vaccines
C.VACaNEHEALTHSCREENNCCIRCLE C)OR C) P:ease answer a‖ questions aboutthe student who w‖ l be receiving the vaccine(s).Answers w‖ l determine whetherthe student can be vaccinated at this time.:f you respond′Ye」 to any of the questions please explain in the space provided.
Yes Yes Yes
to medication, foods, or any vaccines? to a vaccine in the past? No 3. Has the student had a health problem with asthma, lung disease, heart disease, kidney disease, metabolic disease (i.e. diabetes), or a blood disorder? Yes No 4. Has the student had a seizure, brain, or other nervous system problem, including.Guillain-Ba116 Syndrome? Yes No 5. Does the student have cancer, leukemia, AIDS, active tuberculosis or any other immune system probtem? Yes No 6. Has the Student taken cortisone, prednisone, other steroids or anticancer drugs or had radiation treatments in the past three (3) months? 7. Has the student received a transfusion of blood or blood products, or been given immune (gamma) globulin Yes No or an antiviral drug in the past year? Yes No 8. ls the student pregnant or is there a chance she could become pregnant during the next month? Yes No g, Has the student received vaccinations in the past four (4) weeks? No 1. Does the student have any allergies
No 2. Has the student had a serious reaction
Please exploin ony "fes' responses, D. CONSENTTO VACCINATE I certiry the above to be true to the best of my knowledge. I have been given a copy and I have read, or had explained to me, the informa'tion in the Vaccine lnformation Statement for the lnfluenza (Live Virus-Flu Mist) Vaccine (2014-2015). I have had a chance to ask questions and understand the benefits and risks of the lnfluenza. I give permission to vaccinate the student at scheduled school clinic. I authorize the release of my minor child's (until 18 yrs.) immunization records to clinics, physician offices, daycares and school, My authorization rights are available to me in EIPHEFs Notice of Privacy Practices, lf questions you may call 533-3235.
Signature of Consentr (bttSed oυ 15714■ C)
Date:
Payment/lnsurance lnformation for School lmmunizations Provided
ヽ 、
By Eastern ldaho Public Heal.th (EIPHD) Please provide a copy of insurance/Medicaid so EIPHD may bill insuiance provider. Please include back of insurance card.
front and
a. Copy of tnsurance/Medicaid card will then need to be attach"Jio r,, Parental consent Form. lf copy of lnsurance/Medicaid card cannot be copied, lnformation Table below should be completed. a. This form will then need to be attached to Flu Parental consent form. 3.
A copy of insurance/Medicaid card may be faxed or emailed to 208-533-3223 or
[email protected]
a.
lf faxed or Emailed, Please make sure to include Client's Name, Birthdan and School where they will be receiving vaccine. lf Paying Cash (uninsured); you may attach S14 dollars to Flu Parental consent form or a bill will be sent to the address listed on the Ftu Parental Consent
form.
OFFICE USE BELOW Vaccination Date:
[:PH Omce ■250 Ho‖ ipark Drive ldaho Fa‖ s′ :D83401
(208)533-3235
Vaccine 90686 90686
codes
lnsurance
VFC
90471F:u On:y
Medicaid
Medicare
90472
Lot Number
Provider Name
Fluarix (Quad)
9o471
Site
Deltoid
FLu20ne
Left or Right Deltoid
`Quad)
Left or Right Deltoid
906フ 2
G0008
90473
Left or Right
¨ ｈ ¨ ｇ ｉ Ｈ Ｄ
90662
Payer Source
Route
Date of Vis
lM
8-72015
lM
8‐
lM
&7‐20125
72025
Flu‐ Mist
Nう ζ al
iQuad)
Checkttn□
Superttd□
CheCked Out□
Nasal
&72"5 SCanned□
‖¨ 閥 □
