PATIENT INFORMATION & CONSENT (with lot numbers)
Are you sick today or have you had a fever in the past 48 hours?
Yes/ No
Are you pregnant or nursing?
Do you have any allergies? List all medicine or vaccine allergies______________________________________________________
Yes/ No
Yes/ No
Initials
Patient must initial by each vaccine prior to receiving it.
______Influenza
Shot: I am not allergic to eggs or egg products or Thimerosal, do not have acute febrile illnesses (Fever>101º F) and have not had an
anaphylactic reaction or developed Guillain-Barré syndrome after receiving a previous influenza vaccination. VIS given: annual
_____Flu Mist: I am not allergic to eggs or egg products and did not have a reaction to a previous dose. I am not under 2, over 49 or pregnant. I am not
younger than 5 years with asthma or one with more than one episode of wheezing in the last year, receiving aspirin- containing therapy, or have acute febrile or
respiratory illnesses. I am not and will not have contact with severely immunocompromised individuals and have not ceased antiviral therapy within 48 hours. I do not
have any muscle or nerve disorders or other long-term health problems such as heart disease or lung disease or blood disorders. VIS given: 7/26/2013
_____Hepatitis A: I am not allergic to aluminum hydroxide, sodium borate and /or sodium chloride. VIS given: 10/25/2011
_____Hepatitis B: I do not have multiple sclerosis and am not hypersensitive to yeast, formaldehyde, aluminum hydroxide or thimerosal. VIS given: 2/02/2012
_____Meningococcal: I am not pregnant or allergic to thimerosal (Menomune). I am not on anticoagulant therapy (Menveo). VIS given: 10/14/2011
_____MMR (Measles Mumps Rubella): I have not had a reaction to a prior dose or any vaccine components, am not pregnant, do not have acute
febrile illness or a weakened immune system. I have not had another live vaccine in last 4 weeks. VIS given: 4/20/2012 Available at some clinics.
_____Pneumonia: I am over 50, have a chronic health condition or am a child at risk. I have not had a Shingles shot within 30 days or a pneumonia shot
within 5 years and am not pregnant or on immunosuppressive therapy within 2 months or allergic to phenol or bacterial polysaccharides. VIS given: 10/06/09
_____Polio: I was not allergic to a previous dose, neomycin, streptomycin or polymyxin B and am not pregnant. VIS given: 11/08/2011
____TDAP (Tetanus, diphtheria and pertussis): I am not allergic to aluminum phosphate, formaldehyde, glutaraldehyde, 2-phenoxyethanol or a prior
DTaP vaccine and have not had encephalopathy, or progressive neurological disorder. VIS given: TD 1/24/2012 TDAP 5/19/2013
_____Varicella (Chicken Pox): I have not had a reaction to a prior dose or any vaccine components, am not pregnant, do not have acute febrile illness
or a weakened immune system. VIS given: 3/13/2008 Only available at certain clinics
_____Shingles: I have not had pneumonia vaccine within 30 days, am not allergic to neomycin or any component of the vaccine, pregnant or in close contact with
pregnant women who have not had chickenpox, do not have a weakened immune system and am not under 50 yrs old. VIS given: 10/06/09 Available at certain clinics
Patient Information Section (attach photocopy of insurance (front only) and driver’s license.
BCBS ID prefixes not accepted: AMR group 028110, BYP, CGL, FJC, MSR 007013847, TEA, UGD, UDT, UZF,WFQ, XZA, ZGP
with group 000301,000955, 090047, 00700, 075130, ZGZ, Aetna Assurant SRC
____________________/_____________ __________________________
Insured ID
Group#
Patient Last Name
If same person, skip this line
__________________________
Insured Last Name
________________________________
Patient Address: Street
____________________
First Name
_______
Middle I
___________________
First Name
_______
Middle I
___/____/____
___ ___
Birth Date M/D/Y Age Sex
___/___/____
___
Birth Date M/D/Y
Sex
______________________
City
_________
State
__________
Zip
______-_______-______
________________________________ ______________________
Insured (skip if patient) Address: Street
City
_________
State
__________
Zip
______-_______-______
Daytime Phone Number
Daytime Phone Number
________________________________________________
Self, Spouse, Child, Other ________________________/______________
Signature (Person receiving vaccine or Parent or Guardian)
(Circle 1) Insured Relationship
Emergency Contact Person/ Phone Number
If you have any questions, please ask now or check with your physician before receiving the vaccine. I understand the benefits and risks of these
vaccinations and request those indicated above to be given to me. If you experience any significant reactions, see your physician. Please note that by
signing this form you are accepting responsibility for all costs not covered by your insurance. There is a $25.00 service charge for returned checks.
For Clinic Use Only below this point:
Vaccine Administered (nurse checks box by vaccine given)
Influenza
Flu Mist
Hepatitis A
Lot #
Fluzone (SP) >6 mos High Dose (SP) >65 yrs
Flulaval (GSK) >18yTri  Quad Fluarix (GSK) >3 yrs
Flu Mist (Medimmune) 2-49yrs only Quad only
Havarix (GSK), Vaqta (Merck)>1y 12-23 mos, 6 mos
Exp Date
Amount/Site
06
0.5 ml >3y IM
0.25ml < 3y IM
0.1 ml/Nostril
1.0 ml >18y IM
later, Catch-up is 0,6 months.
Hepatitis B
Injection Site
Left Right
Intranasal
Left Right
0.5 ml < 18y IM
Energix (GSK) Recombivax (Merck) 0, 1-2 mos and 3-
1.0 ml > 19y IM
Left Right
18 months, Rec schedule is 0,1 and 6 months Catch-up is 0,4 16 wks
0.5 ml < 19y IM
Meningococcal Menveo (Nov) (2-55y) Menactra (SP) (9ms-55y)
Menomune (SP) (2 and up, use for >55y) child 11-12,16 yrs
MMR
 MMRII(Merck) 12-15 mos, 4-6 years. Catch-up 0,4 wks
Pneumonia
Pneumovax (Merck) for adults>50 or child>18 at risk
Polio
IPOL (SP) if unvaccinated adult, 0, 4, 26wks
TDAP
Boostrix (GSK) 11-64y Adacel(SP)>10y, 1 every 5-10yrs
0.5 ml
0.5 ml
0.5 ml
0.5 ml
0.5 ml
0.5 ml
IM
SC
SC
IM
IM
IM
Left Right
0.5 ml
0.65 ml
SC
SC
Left Right
Left Right
Chicken Pox
Shingles
Nurse Signature:
 Varicella(Merck) 12-15 mos , 4-6 yrs. Catch-up 0,4-12wks
Zostavax (Merck) >60, 50 with BCBS (5/8th syringe)
RN Date:
Payment Amount:
CASH CHECK#
OTHER:
Left
Left
Left
Left
INSUR
Right
Right
Right
Right
BILL