YOUR MEDICAL HOME - Flu Consent Form
Please fill in your details and mark the location.
First name
Last name
Email
Phone Number
Personal Address
Date of Birth
Gender
Guardian Name
Guardian Phone Number
Guardian Address
Is the person receiving the vaccine at least 2 years old?
Yes
No
Has the person received the vaccine ever has a severe allergic (hypersensitivity) reaction to egg, chickens, or chicken feather?
Yes
No
Does the person receiving the vaccine have a history of Guillain-Barre syndrome or a persistent neurological illness
Yes
No
Has the person received a live vaccine within the past 30 days (i.e. MMR, Rota, Teq/Rotarix)? * if yes, it is recommended to space live vaccines by >4 weeks for full efficacy.
Yes
No
Is the person receiving the vaccine pregnant?
Yes
No
Is the person receiving the vaccine allergic to Neomycin, Thimerosal, (Preservative found in contact lens solution), any vaccine ingredient, or latex?
Yes
No
For children 6 months - 8 years: Have they received 2 or more doses of influenza vaccine since 2015?
Yes
No
For children and adolescents age 2-17 years: Is the child taking long-term aspirin or aspirin-containing therapy?
Yes
No
Insurance Information:
Please mark if you will be filling on insurance or self pay.
Insurance or Self Pay
Insurance
Self Pay
Are you the primary insured
Yes
No
Relation To Primary
Insurance Subscriber
Subscriber DOB
Employer
Insurance Type:
HMO
PPO
POS
HSA
Medicare
Other
Group #
Your Signature
*
Clear
Today's Date
Location that you will be receiving your shot?
Your Medical Home (Bridge City)
Heritage Lakes (Pflugerville)
Other
If other please list the name of the location or organization (ex. city hall)
Submit
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