Influenza Vaccine Consent Form printable pdf download

2016-17 School Based Influenza Vaccine Consent Form

Bryan County Health Department

Section 1: Information about Student to Receive Influenza Vaccine (please print clearly)

STUDENT’S NAME (Last)

(First)

(M.I.)

SCHOOL NAME:

STUDENT’S DATE OF BIRTH

STUDENT’S AGE

GENDER:

M /

TEACHER

GRADE

(mm/dd/yyyy)

ETHNICITY

RACE

African American, White,

PARENT/ LEGAL GUARDIAN’S NAME

(Please Circle)

Hispanic or Latino, American Indian, Asian,

Not Hispanic/Latino

Hispanic Latino

Alaska Native, Native Hawaiian, Other Pacific

HOME ADDRESS

PARENTAL/ GUARDIAN PHONE NUMBER(S)

CITY

STATE

ZIP CODE

PARENTAL/ GUARDIAN E-MAIL

INSURANCE INFORMATION: Do you have Insurance that covers vaccines?

Yes /

Provide the insurance information for the provider selected

& attach a copy of the insurance card to this form

Please check health insurance provider below:

Wellcare

Medicaid

Other________________

Policy Holder Name_______________________________

Amerigroup

Peachcare

Cigna

Group#_________________________________________

Blue Cross Blue Shield SHBP

PeachState

No Insurance

Aetna

Member ID #____________________________________

Section 2: Medical Information

Has the student received any vaccines in the last four weeks? If yes, please list:

Yes

When was the student last vaccinated for flu?

DATE:

Has the student ever had a serious reaction to eggs?

Yes

Has the student ever had a serious reaction to any influenza vaccine?

Yes

Is the student on long term aspirin or aspirin-containing therapy (For example: does the student take aspirin everyday)

Yes

Does the student have any significant or chronic (long term) health conditions? (For example: diabetes, sickle cell disease,

Yes

heart conditions, lung conditions, seizure disorders, cerebral palsy, muscle or nerve disorders)

Does the student have a weak immune system (for example, from HIV, cancer, or medications such as steroids or those used to

Yes

treat cancer)?

Is the student or could the student be pregnant?

Yes

Has the student ever had Guillain-Barre Syndrome (GBS)?

Yes

Section 3: Consent:

If this consent form is not filled in completely, signed, dated, and returned, the student will not be vaccinated at school.

If you do not wish for your student to receive the flu vaccine at school, do not sign or return this form.**

I GIVE CONSENT

for the student named above to receive the injectable flu vaccine at the school location from the COUNTY HEALTH

DEPARTMENT.

I acknowledge that the student and medical information provided above is correct. I have been given a copy of the Vaccine Information Statement

for the influenza vaccine and the NOTICE of PRIVACY POLICY FORM. I have had a chance to ask questions which were answered to my satisfaction. I understand the

benefits and risks of the influenza vaccine that will be given to the student that I am authorized to represent. I understand that participation and receipt of the

influenza vaccine through this program is completely voluntary. By signing below, I give permission for the student listed above to receive the injectable influenza

vaccine.

Signature of Parent/Legal Guardian: ________________________________

Date: _________________________

FOR CLINIC USE ONLY

Inactivated Influenza

Adm Route:

Date Dose

Mfg:

Lot #

Exp

VIS

Signature of Nurse: