Microsoft word - ped consent form 2013

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: ______ / ______ / ______

Source: http://www.immanuellutheranchurchandschool.org/resources/PEDCONSENTFORM2013.pdf