CLARKE COUNTY PUBLIC HEALTH
FLUMIST VACCINE CONSENT AND SCRENING FORM CLARKE COMMUNITY SCHOOL CLINICS
VACCINE WILL BE ADMINISTERED OCTOBER 19TH
**********PLEASE COMPLETE BOTH SIDES**********
PATIENT INFORMATION **PLEASE PRINT**
Full Name
CLARKE COMMUNITY SCHOOLS
GRADE/CLASS
Date of birth
Address
Gender
City/ State /
Zipcode
Physician Name
Phone Number
Physician Phone
MALE
FEMALE
CONSENT FOR VACCINATION **PLEASE READ BEFORE SIGNING AND DATING**
I have received or have been offered a copy of the current Influenza Vaccine Information Sheet and screening form prior to
vaccination. I have had a chance to read and ask questions. I understand all the risks and benefits involved.
I understand that if any effects are experienced, it will be my responsibility to follow up with a physician at my expense. Mild
reaction to nasal spray may include runny nose, nasal condensation cough, fever headache, sore throat, chills, fatigue,
wheezing, abdominal pain, vomiting or diarrhea.
FLUMIST NASAL SPRAY VACCINE CANNOT BE GIVEN to anyone younger than 2 or older than age 50, pregnant
women, anyone with weakened immune system, anyone with long-term health conditions such as heart, kidney, liver,
metabolic disease (diabetes), or asthma/wheezing during the past year, nerve disorder (cerebral palsy), long-term aspirin
treatment, or are living with someone with a severely weakened immune system.
I GIVE CONSET to Clarke County Public Health to administer the vaccine. I expressly release from any liability the above
name organization and individual giving vaccine(s). I, for myself, my heirs, executors, and assigns hereby agree to release the
sire provider and employees from any and all claims arising out of, in connection with, or in any way related to my receipt of
vaccine.
If your health care provider is UnityPoint Osceola, they will be notified of the vaccine administration.
(Print) Name of Parent/Guardian
Signature of Parent/Guardian
METHOD OF PAYMENT **PLEASE CHECK ONE AND FILL INFORMATION**
NO insurance or insurance does not cover vaccines
Medicaid (TITLE XIX)
Please print Medicaid number here:
$30.00 Check
Makes checks payable to Clarke County Public Health
$30.00 charge to Credit/ Debit/ HSA
Card Holder’s Name:
Date
Last 4 numbers:
Please print the card holder’s name:
Date of birth:
Policy number:
NOTE: I understand that if my insurance policy does not cover the cost of vaccines I will be held responsible for the
full payment of vaccine
FOR STAFF USE ONLY
ROUTE/ DOSEAGE
Administered by
Bill BlueCross BlueShield
Other Insurance
VACCINE LOT #:
__ Nasal spray 0.2 ml
bilateral
S. Eddy RN
M. Hickenbottom
RN
M. Blain RN
FluMistTM, Influenza Virus Vaccine Live, Intranasal
Vaccine Information and Screening Form
Before you get FluMist, please read this information sheet, answer the question and return the form to your nurse or doctor
Why Get Vaccinated with Influenza Vaccine?
Influenza or the “flu” strikes around 1 in 10 persons in the United States each winter. Although it is often confused with the common cold, the flu is
more severe. The typical flu includes fever, severe muscle aches, fatigue, headache, cough, sore throat and runny nose. When an adult of working
age get the flu it can last as long as 10 days. Most healthy adults recover from the flu without other health problems. Vaccination is recommended
as the best way to prevent influenza. Because flu viruses change constantly, flu vaccines also change and the vaccine must be given each year.
What is FluMist and What Benefits Can I Expect?
FluMist is an influenza vaccine that is given as a mist into the nose. Flumist contains three live influenza virus strains, which have been weakened.
When the weakened influenza viruses in FluMist enter the nose, the body develops an immune response. Your body’s response to these live
vaccine viruses may help prevent the flu for the entire season. However, FluMist does not prevent the flu for all of the other people who take it.
What Side Effects Might Occur and Who Should Not Take FluMist?
In studies of 7500 people between the ages of 5 and 49, side effects were generally mild and temporary. Runny nose was the most common. Other
included headache, cough, sore throat, tiredness/weakness, irritability and muscle aches. Additional side effects not seen in studies are possible
when FluMist is used in a larger population. There are risks associated with all vaccines, including the FluMist. FluMist should not be used, under
any circumstances, by anyone with an allergy to any part of the vaccine, including eggs; in children and adolescents receiving aspirin therapy; in
people with certain medical conditions, including asthma or reactive airways disease should not get FluMist. Ask your health care provider if
FluMist is right for you.
Certain people must not get FluMist. You must answer each of the questions below, and they must be reviewed by the nurse or doctor to see if you
can get FluMist. Your practitioner will keep this questionnaire and the information collected in a confidential manner.
How old are you? _______
The nurse or doctor must review Your Answers:
Are you allergic to eggs?
Yes
No
Yes
No
Do you have diabetes or another metabolic disease?
Have you ever had a bad reaction to FluMist?
If you are female, are you pregnant or breastfeeding?
Do you have AIDS, HIV, cancer or have you received
an organ transplant?
Did a doctor ever tell you that you have any other
problem with you immune system?
Is there anyone living with you who has an immune
system problem?
Did a doctor ever tell you that you had asthma or
reactive airways disease
Do you have any breathing or lung problems such as
chronic bronchitis, emphysema, or cystic fibrosis?
Have you ever had a heart attack or a stroke?
Did a doctor ever tell you that you had Guillain-Barre
syndrome?
Do you have kidney disease?
Do you plan to receive any vaccinations within the next
month?
Are you taking any prescription medicines to prevent or
treat the flu?
Do you have a heart disease such as angina or congestive
heart failure?
Do you have a blood disease like sickle cell disease or
thalassemia?
Do you currently have a fever, cold or other respiratory
illness?
Have you received any vaccination within the last
month?
Where to Report Adverse Reactions (Side Effects):
If you have a reaction after getting FluMist, you should contact your nurse or physician right away. You are encouraged to report any reaction from
the vaccine to the FDA (the Food and Drug Administration) using the Vaccine Adverse Events Reporting System (VAERS) form available at
http://secure.vaers.org/VaersDataEntryintro.htm. The VAERS reporting form and instructions for submitting it can be obtained by calling toll-free
1-800-822—7967 or toll-free fax at 1-877-721-0366. You may also submit request to VAERS via e-mail to info@vaers.org.
I have read the above information about FluMist and have truthfully answered all of the questions on this form. I have had a chance to ask
question about and fully understand the benefits and risk of the vaccination with FluMist.
_________________________________________________
Printed Name of Person to Receive Vaccine or
Parent or Guardian
FluMist given on (Date) ______ (Time) _______ Lot Number ___________
_________________________________________________
Signature of the person received Vaccine Date or
Parent or Guardian
________________________________________________________
Signature of Vaccine Administrator Date