HomeMy WebLinkAboutFlu 2021 Consent FormVisiting Nurse Association Date: 10/01/2021 Location: Robert A. Lee Rec Center Gym_ ADULT
319-337-9686 VIS: Flu Shot-(IIV)-8/7/15 FluMist-(LAIV4)-8/7/15 Pneumonia-(PPSV23)-4/24/15 Pneumonia-(PCV13)-11/5/15
Patient Information (Please Print)
Last Name: First: Gender: M / F
Address: City: State: Zip Code:
Phone: Birthdate: Age:
Social Security: Physician:
(NA if self/contract pay)
Patient Consent
Special Cautions (See Vaccine Information Sheet for details)
1. If you have any of the following, obtain vaccination under your doctor’s supervision
* Have had a serious allergic reaction to eggs or a vaccine component , including Thimerosal
*Have had previous severe reaction to flu/pneumonia shots
*Have an active neurological disorder (delay until stabilized ) or history of Guillain-Barre Syndrome
2. If you have an acute infection with fever over 100 F, delay immunization until you are recovered.
3. FluMist is limited to healthy persons, aged 2-49. Not approved for pregnant women or 4 and under with asthma/recurrent wheezing.
4. High Dose Influenza vaccine is for individuals, aged 65 years and older to help boost immune response.
I have read the information sheet about the influenza/pneumonia vaccine. The information I have provided above is correct and true
to my knowledge. I understand the benefits and risks of the vaccination and request that the vaccine be given to me or to the person
listed above, for whom I am authorized to make this request. If insurance denies payment, or my original method of payment is
rejected, I agree to be personally responsible for full payment . I understand all information obtained by the VNA will be used only
for treatment, payment, or health operations.
Please initial I authorize:
Influenza Regular Injection
Signature of person to receive vaccine or authorized to sign Date
Flu: $36 ($33 cash/check now) FluMist: $38 ($35 cash/check now) High-dose Flu: $52 ($49 cash/check now) Pneumonia: PPSV23 $110 or PCV13 $185
Payment Information (Please show insurance card to receptionist)
Medicare B: Medicare #_
MC Replacement: Plan Name Policy # Phone
Primary Insurance Carrier: Claims Address: _Phone Policy
# / Member ID_ Group # / Employer Policy
Holder: Patient relationship to policy holder: Self Spouse Child Other
Patient Pay Full: Amount $_ cash check #
Voucher Payment: Voucher #
Company Pay Full Company Name City of Iowa City
To be completed by VNA Nurse
Flu Vaccine IM: L Deltoid R Deltoid Other Lot Number
Dose: 0.5 cc Regular 0.5 cc Pres Free
Flu Mist (live, bilateral intranasal) Lot Number
High-dose Flu Vaccine, 0.5 cc, IM: L Deltoid R Deltoid Other Lot Number
Pneumonia Vaccine, 0.5 cc, IM: L Deltoid R Deltoid Other Lot Number
***Nurse Signature