NEW RIVER VALLEY PEDIATRICS
2009 H1N1 INFLUENZA ENCOUNTER
COMPLETE THE DESIGNATED SECTIONS:
Patient’s Name (Last, First, MI)__________________________________________________________________________________________________
Address____________________________________________________________________________________________________________________
Birth Date__________________
Gender______
Home Phone_____________________
Cell Phone_____________________
List Allergies:
BRIEF HEALTH HISTORY
(Complete this section for the person being vaccinated today)
YES

NO

Have you ever had a serious allergic reaction to eggs or the antibiotic gentamicin?


3.
Have you ever had a serious reaction to a previous dose of seasonal flu vaccine?


4.
Have you ever had a Guillain-Barre syndrome (GBS), (i.e. paralysis) within 6 weeks after receiving a flu vaccine?


5.
Do you have any other serious allergies that you know of?
If yes, please list____________________________________________________________________________


6.
Are you taking any prescription medication to prevent or treat flu?


7.
Do you have asthma, wheezing, difficulty breathing, or lung disease?


8.
Do you have a long-term health problem such as heart disease, kidney disease, metabolic disease
(e.g., diabetes), or blood disorders (e.g. steroids)?


Do you have a weakened immune system caused by cancer, cancer treatment (e.g., x-rays or drugs),
HIV/AIDS, other disorders, or medicine (e.g., steroids)?


Do you live with or have close contact with anyone with a severely weakened immune system requiring care in a
protected environment (ex. hospitalized family member receiving chemotherapy)?


11.
Are you 18 years old or younger AND taking aspirin or other aspirin-containing therapy?


12.
Have you received an MMR (measles/mumps/rubella), varicella (chickenpox), or the live intranasal seasonal
influenza vaccine (LAIV) within the past 4 weeks?


13.
Do you have a muscle or nerve disorder (such as cerebral palsy) that can lead to breathing or swallowing problems?


14.
Are you pregnant or nursing?


1.
Have you already been vaccinated with 2009 H1N1 vaccine?
If yes, please tell us the date(s): ______/______/______ ______/______/______
Please circle type:
nasal spray
shot
nasal spray shot
2.
9.
10.
PLEASE NOTE: If your child is younger than 10 years old, 2 doses of the H1N1 influenza vaccine are required. Each dose will be
administered approximately one month apart.
It is recommended that you wait 15 minutes at this site following your injection because an allergic reaction could occur after the
administration of any vaccine. If you choose to leave this site prior to 15 minutes after your injection and you experience shortness of breath
or a tingling sensation in your mouth or throat, seek medical care immediately.
_____________________________________________________________________________
Signature of Patient, Parent/Legal Guardian, or Person Acting in Loco Parentis
__________________________
Date
__________________________________________________________
____________________
Signature of Nurse
Date
NEW RIVER VALLEY PEDIATRICS
2009 H1N1 INFLUENZA ENCOUNTER
INFORMED CONSENT FOR INFLUENZA IMMUNIZATION
I hereby authorize the doctors, nurses, nurse practitioners, or other licensed health care providers of New River Valley Pediatrics to immunize me or my
child named above. I understand the risks and benefits of the immunizations checked below and have had the opportunity to ask questions. I have
received 2009 H1N1 Influenza Vaccination Information Statements (VIS) for the H1N1 influenza shot and for the nasal spray. I agree that my or my
child’s immunization record and date of birth may be shared with other health care providers. I understand that this information will be used by health
care providers for the care of me or my child and for statistical purposes only. I understand that this information will be kept confidential. The Deemed
Consent for blood borne diseases has been explained to me and I understand it. I understand that medical records must be kept for a period of 10 years
after my last visit, five years after age 18, or five years after death.
PATIENT CONSENT FOR GENERAL PRIMARY CARE
NOTICE OF DEEMED CONSENT FOR HIV, HEPATITIS B OR C TESTING
New River Valley Pediatrics is required by § 32.1-45.1 of the Code of Virginia (1950), as amended, to give you the following notice:
1.
If any NRV Pediatrics health care professional, worker, or employee should be directly exposed to your blood or body fluids in a way that may
transmit disease, your blood will be tested for infection with human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A physician
or other health care provider will tell you the result of the test. Under Virginia Code § 32.1-45.1(A), you are deemed to have consented to the
release of the test results to the person exposed.
2.
If you should be directly exposed to blood or body fluids of a NRV Pediatrics health care professional, worker, or employee in a way that may
transmit disease, that person’s blood will be tested for infection with human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A
physician or other health care provider will tell you and that person the result of the test.
RECEIPT OF THE NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received the notice of Privacy Practices from New River Valley Pediatrics.
RECORD KEEPING
I understand that medical records will be retained for ten years after the date of the last visit or for five years following patient’s death. In the case of a
minor, the record will be retained ten years after the last visit or for five years after age 18, whichever comes later. I authorize NRV Pediatrics to release
records necessary to support the application for payment by Medicare, Medicaid, and other health care benefits. I request the third party payer to pay
any authorized benefits to NRV Pediatrics on my behalf. I understand that this consent will remain in effect as long as my dependent or I receive care
from NRV Pediatrics or until I withdraw it.
VACCINE ADMINISTERED
▄ Influenza, Novel H1N1
_____________________________________________
___________________________________________________
Printed Name, Parent/Legal Guardian, Person Acting in Loco Parentis
ITEM CODE
ITEM CODE
H1N1 - MIST
H1N1 – PED - PC
H1N1 – PED - PF
H1N1 – 3PLUS - PC
H1N1 – 3PLUS - PF
CONTRAINDICATION DESCRIPTION
LOT NUMBER
Signature
Date
CONTRAINDICATION TYPE
ROUTE
NS
IM
IM
IM
IM
__________________________________________________________________________
SIGNATURE OF NURSE
_______________
INJECTION SITE
EFFECTIVE UNTIL DATE
PROVIDER #
__________________________________
DATE