Clinic Site: __________________________
Flu Prevention Program 2013 PEDIATRIC INFLUENZA IMMUNIZATION CONSENT Patient Name Date of Birth (As it appears on insurance card) M F ____/____/____ ___ yrs ____ mos Address: No. and Street Name (No PO Box Please) City State Zip Home or Cell Phone: Work Phone: PRIMARY INSURANCE INFORMATION: Please check your insurance; fill in your insurance ID# and policyholder’s name. CONNECTICUT STATE INSURED EMPLOYEES ONLY Insurance ID
Name of insured person if other than patient:
________________________________________________________ Direct Payment: I understand I will receive a bill from WCHC for any portion of this claim my insurance company does not pay and I agree to pay the bill in full within 30 days of receipt. PLEASE ANSWER THE FOLLOWING QUESTIONS
1. Has your child had a severe allergic reaction (including but not limited to hives) to eggs, latex or the
preservative thimerosal? If yes, circle which one.
2. Has your child ever had a reaction to any vaccine? If yes, which vaccine. ___________________________ Yes No 3. Has your child ever been diagnosed with Guillain-Barré Syndrome?
4. Is your child sick with a fever of >100 degrees today?
CHILDREN TWO YEARS AND OLDER ONLY: Answer the following ONLY if your child is interested in receiving FLUMIST.
A. Does your child have chronic health issues such as: diabetes; heart, lung, kidney or liver disease; COPD
or asthma, or a neuromuscular/neurological diseases or have a weakened immune system?
B. If your child is ages 2 – 5 has he/she had a history of recurrent wheezing. Not applicable
C. Is your child receiving aspirin therapy or aspirin-containing therapy?
D. Is your child pregnant or is there a chance she might be pregnant?
E. Has the child taken an antiviral medication such as Tamiflu® or Relenza® within the last 48 hours?
F. Has the child been immunized with a live vaccine (MMR, chicken pox, shingles, yel ow fever or oral typhoid)
G. Is your child in close contact with an immunosuppressed person who requires protective isolation?
IF YOUR CHILD IS 8 YEARS OLD OR YOUNGER, PLEASE ANSWER THE FOLLOWING:
Has your child ever received a flu vaccine?
Has your child received two doses of flu vaccine since July 2010?
I have read the Influenza Vaccine Information Statement dated 07/26/2013. I have had a chance to ask questions and I understand the benefits and risks of the vaccine. I request that the vaccination be given to me (or to the person for whom I am authorized to make this request). I authorize the
release of any medical or other information necessary to process the insurance claim or for other public health purpose. I have read the Notice of
Privacy Practices. I agree to pay all unpaid charges billed to me by Western Connecticut Home Care.
Parent Signature: ________________________________________ Print Name: ________________________________________ STAFF USE ONLY Place vaccine label here or complete: Vaccine Brand:______________________________ Lot #: ___________________ Exp. Date:____________ Site: L Arm R Arm Intranasal L Thigh Administered by: ___________________________ Date: ______ / ______ / ______
CAPÍTULO II GLOSARIO DE TÉRMINOS Definiciones: De acuerdo a la finalidad, contenido, uso y medio de emisión, se utilizan en el Manual de Procedimientos los siguientes términos, que serán explicados a continuación. Acto Administrativo: Es la ejercitación de la potestad administrativa que deriva del ejercicio, por parte de un órgano de la Administración Pública, de la