Flu Vaccine at the Community Bridge ClinicPatient's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Primary Care Provider(Required) Patient is(Required) Self Child Child's School(Required) School Grade(Required) Parent/Guardian Name(Required) First Last Parent Guardian Phone Number(Required)Injection consent (child)(Required) I would like to have my child receive the injectable/shot (inactivated) flu vaccine Injection consent (self)(Required) I would like to receive the injectable/shot (inactivated) flu vaccine Patient has (check one)(Required) has private insurance has HUSKY/Medicaid has no insurance is Native American or Alaskan Native Health QuestionsIs patient sick and/or have a fever?(Required) Yes No Is patient allergic to eggs?(Required) Yes No Has patient ever had Guillain-Barre syndrome?(Required) Yes No Has patient ever had a flu shot before?(Required) Yes No* *If patient is less than 9 years old and never had a flu vaccine, 2 doses are needed a month apart. Has patient ever had a bad reaction to a flu shot?(Required) Yes No Click here to review the Influenza (Flu) Vaccine (Inactivated or Recombinant) information statement.VIS Acknowledgement I have read or have had explained to me the information about the influenza vaccine from the attached Vaccine Information Statement (VIS). I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the influenza vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request. I give permission for my insurance to be billed at time of visit. I understand that a sliding scale will be available for those without insurance. I authorize the release of any medical information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency for services provided. I understand and acknowledge that I have read and understand this consent.Patient or Parent/Guardian Signature(Required) Signature Date(Required) MM slash DD slash YYYY
