ECU Physicians: Flu Vaccine Program 2013-2014 Patient Consent/Vaccine Administration Record
Social Security Number: XXX-XX- _ _ _ _
Information about the individual receiving the vaccination (Please print):
Last Name: _______________________________ First Name: ____________________________ MI: ____ Date of Birth: _____________ Sex: M / F
Address: ___________________________________ City: ____________________ State: _______ Zip: _____________ Phone: _____________
Banner ID #: _____________________ Department: _______________________________ Circle One: Employee
Employee Family
Student
FILL OUT THIS SECTION IF YOU WANT US TO SEND NOTIFICATION OF VACCINATION TO YOUR PRIMARY CARE PROVIDER:
Primary Care Physician: _________________________________________ Name of Practice: _____________________________
Office Address: _________________________________________ City: _____________________ State: ____________ Zip: ______________
________________________________________________________________________________________________________________________________
Insurance: State Employees # ___YPYW______________________________
Circle one: Self Spouse Child of_____________
Other Primary Insurance: ____________________________
ID#:_______________________________ Group#: _______________________
Please answer the following questions by placing an X in the answer box:
YES
NO
DON'T
KNOW
1. Are you feeling sick today?
2. Do you have allergies or reactions to medications, foods, latex, or any vaccine component?
If so, please list: _________________________________________________
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have a long term health problem such as heart disease, lung disease, asthma, kidney disease, diabetes, or
other metabolic disease, active tuberculosis, anemia, or any other blood disorder?
5. Do you have cancer, leukemia, AIDS, or any other immune system problem?
6. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
7. Have you ever had a seizure, or been diagnosed with Guillain-Barre syndrome, or a nervous system problem?
8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin
or an antiviral drug?
9. For women: are you pregnant or nursing? Could you become pregnant during the next month?
10. Have you received any vaccinations in the past 4 weeks?
Please read the following statements and sign on the signature line below:
I have had a chance to read the appropriate Vaccine Information Statement and to ask questions which were answered to my satisfaction. I
understand the benefits and risks of the below checked vaccine(s) and consent that it be given to me or to the person named below for
whom I am authorized to provide consent.
___________________________________________________________________________________________________________________
Signature of individual to receive vaccine or person authorized to make the request (parent/guardian)
Date: _____________
***************It is recommended that you wait 15-20 minutes after receiving the vaccine to be observed for any adverse*********************
NO INSURANCE (Employee or Student, No Charge Spouse or Child, $10.00)
Dx: V04.81
Admin code 90471
Vaccine sticker or information here:
NDC:
Lot#:
Ex-date:
Vaccine Administration Information: CDC VIS: 7/26/13
IM
90656
High Dose
Deltoid Area:
90662
Intradermal 90654
FluMist
90672
/
Administering Immunizer Name and Title
Right
/2013
Date
Left