Screening Questions

2017-2018 Insurance Information Form: The completion of this form is necessary for every vaccine recipient. If no insurance information is available, please fill out as much as possible using existing information.

Information about the person to receive vaccine (please print): *Required Fields

Name: (Last, First, MI)* / Date of birth: *
______
Month Day Year / Age* / Sex: (Circle)*
Male Female
Street Address:*
City:*
Lexington / State: * MA / Zip:* / Phone:*
( )

Insurance Information: Include the whole member ID number and any letters that are part of that number

Name of Insurance Company:* / Member ID Number:* / Group ID Number: (if available)
Medicare Number: / Is Medicare Primary?
Yes No / Is Subscriber Employed?
Yes No

If person getting vaccinated is not the subscriber, please complete the following:

Subscriber’s Name: (Last, First, MI)* / Subscriber’s Date of Birth: *
______
Month Day Year / Sex: (Circle)*
Male Female
Subscriber’s Street Address:* (If different from address above)
City:* / State:* / Zip: * / Phone:*
( )
Patient Relationship to Subscriber: (Circle)* Spouse Child Other

I give permission for my insurance company to be billed.

X ______Date: ______

(Signature of patient, parent or legal guardian)

**********************************************************************************************Place Photo Copy of All Insurance Cards below:

Please check YES or NO for each question. If you answer “YES” to any of the questions, it is possible that may not be vaccinated today. The Public Health Nurse may ask additional questions or recommend that you contact your health care provider.

Screening Questions to receive the Injectable Flu Vaccine “ Flu Shot” / NO / YES
1. Do you have an allergy to eggs or to a component of the flu vaccine?
2. Have you ever had a serious reaction to a flu vaccine in the past?
3. Have you ever had Guillain-Barré Syndrome?

For Children under the age of 19 Only:

To help us determine if your child is eligible to receive vaccines from the Vaccines for Children Program, please check one of the boxes below. Your child will receive flu vaccine whether or not they are eligible.

5 Is enrolled in Medicaid (includes MassHealth and HMOs, etc., if enrolled through Medicaid)

5 Does not have health insurance

5 Is American Indian (Native American) or Alaska Native

Screening Questions

5  Has health insurance and is not American Indian (Native American) or Alaska Native

CONSENT FOR CHILD’S VACCINATION: I have read or had explained to me the 2017-2018 Vaccine Information Statement for the influenza vaccine and understand the risks and benefits.
I GIVE CONSENT for my child named at the top of this form to get vaccinated with this vaccine. Children younger than 9 years of age may need 2 doses of vaccine. (If this consent is not signed, dated and returned, my child will not be vaccinated.)

______/____/_____
Signature of Parent/Legal Guardian Date
ADULT
or
CHILD / Date of
Service / Vax
Type / Vax Mfgr / Lot No / Exp Date / Dose (mL) / State
Supplied / Preserv
Free / Injection Route / Injection Site
(Circle) / Date
On
VIS
ADULT / Multi-Dose vial
FLUZONE / Sanofi / UI829AE / 6/30/18 / 0.5 / No / No / IM / R Arm L Arm / 8/7/15
CHILD/
ADU w/o Ins / Pre-filled Syr.
FLULAVAL / GSK / PN75E / 5/31/18 / 0.5 / Yes / Yes / IM / R Arm L Arm / 8/7/15
ADULT
(SENIOR) / Pre-filled Syr.
FZ ‘High Dose’ / Sanofi / / /18 / 0.5 / No / Yes / IM / R Arm L Arm / 8/7/15

For Clinic/Office Use Only:

Signature of Vaccinator:______Date:______