FLU VACCINE CONSENT FORM
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3375 Koapaka Street, Suite G-320, Honolulu, HI 96819
_______
Staff use only
I. Participant Information – Please print information below
Maui
Date of Birth
Participant Name
Gender
(mm/dd/yyyy)
☐M ☐F
Enter Your Name
__/__/____
Home Address
City/Zip
Phone #
Enter Home Address
Enter City & Zip
(_ _ _) _ _ _-_ _ _ _
PRIMARY Insurance Name
RELATIONSHIP to Cardholder
Subscriber NAME (if different from participant)
Choose Insurance
Enter Subscriber’s Name
Choose Relationship
Subscriber’s DOB (mm/dd/yyyy)
Subscriber NUMBER
Group Number
__/__/____
Enter Subscriber Number
Enter Group Number
SECONDARY Insurance Name (if any)
Subscriber NAME
Enter Secondary Insurance (if any)
Enter Subscriber Name
Subscriber’s DOB (mm/dd/yyyy)
Subscriber NUMBER
Group Number
__/__ /____
Enter Subscriber Number
Enter Group Number
If yes, please fill out Medicare number (if not already above):
Enter Medicare Number
Do you have Medicare?
☐NO
☐YES
RELATIONSHIP to Cardholder
Choose Relationship
II. Health and Medical Information
Are you 18 or older?
☐ Yes ☐ No
Are you pregnant?
☐ Yes ☐No
Are you allergic to eggs or egg products?
☐ Yes ☐ No
Are you allergic to neomycin or polymixin?
☐ Yes ☐ No
Do you have a cold, fever or active illness?
☐ Yes ☐ No
Have you ever had an allergic reaction to the seasonal flu vaccine?
☐ Yes ☐ No
Have you ever had Guillain-Barre Syndrome (GBS)?
☐ Yes ☐ No
Information About the Vaccine. The flu vaccine builds up your body’s ability to resist exposure to the flu virus. If you do get the flu after
receiving the vaccination, the symptoms are often milder. Most people have no serious side effects from the vaccine. A small percentage of
people may develop tenderness at the injection site, fever, chills, headaches, muscular aches or central nervous system disorders. Less
common side effects include allergic reactions, such as hives or allergic asthma, and Guillain-Barre syndrome (GBS).If it is your first time
being vaccinated, it’s recommended you remain in the clinic area for at least 10 minutes.
Consent and Waiver I hereby affirm that all of the information I have provided is true and correct. I have read the above information and
understand that it is my responsibility to seek the advice of a physician if I answered “Yes” to any of the questions above or have any concerns
about whether I should receive the flu vaccine.
I understand the benefits and risks of flu vaccinations and that there may be additional unknown risks and I hereby consent to the
administration of the flu vaccine. I waive and release any and all rights and claims that I and/or my heirs have or may have against
Pharmacare, its employees, agents, affiliates and their representatives because of any injuries or illnesses suffered by me in connection with
the administration of the flu vaccine or related services. In the event of an anaphylactic reaction, I authorize clinician to administer
diphenhydramine or epinephrine in appropriate weight-based dosing to treat reaction symptoms. I understand that I will not receive any
medication in the event of an anaphylactic reaction without my verbal consent.
I have had the opportunity to read Pharmacare’s Notice of Privacy Practices to my satisfaction prior to consent. I acknowledge that I am
responsible for communicating the information provided to me about my vaccination to my primary care provider if I have one. I understand
that I am responsible for payment of amounts not covered by my medical insurance plan, including co-payments and deductibles.
____________________________________________
Select a date
Signature of Participant
Date
PHARMACARE USE ONLY
Date Administered:
Payment type (Circle One)
CC
Vaccinator Signature:
Check
Cash
Injection Site:
HR
_______R
2015-2016 Influenza Vaccine VIS (Inactivated) 8/7/15
_______L Deltoid
Vaccinator Title: ___ Kahu/CRH
___ RN ___ LPN ___ PharmD ___ Int.
www.pharmacarehawaii.com
Date Received:
AFLURIA Prefilled Syringe
Manf: bioCSL
Lot: U54205
Exp: 5/27/2016
TransactRx
Staff use only