Henry County Health Department

School Flu Vaccine Program 2014

Student or Faculty (circle one)

Grade ______

Legal Name Only

Last name______First name ______Middle name______

Date of birth ______Age ____ Race______Circle Gender Male / Female

Address ______City ______Zip code______

Home Phone______Cell Phone ______

Emergency Contact Name ______Number ______

PLEASE ANSWER ALL QUESTIONS

Please check if any of the following restrictions apply to the person receiving vaccines today:

 50 years of age or older

Asthma or under 5 years of age with wheezing in the past year

Pregnant

Received any vaccines in the last 28 days

Any long term health problems affecting the immune system (heart, lung, liver, kidney, neurovascular,

Metabolic (diabetes) or blood disease (sickle cell or HIV) other ______

Long term aspirin therapy

Close contact with patients requiring a protected environment (such as bone marrow transplants)

NONE OF THE ABOVE

** IF ANY OF THE ABOVE QUESTIONS ARE CHECKED YOU WILL NEED TO RECEIVE THE INJECTABLE FLU VACCINE. **

Serious allergy to eggs or another vaccine component

History of Guillain-Barre Syndrome or serious reaction to the flu vaccine in the past

NONE OF THE ABOVE

**IF ANY OF THE ADDITIONAL QUESTIONS ARE CHECKED, YOU WOULD BE REQUIRED TO CONTACT YOUR DOCTOR AND OBTAIN WRITTEN DOCUMENTATION PRIOR TO RECEIVING THE FLU VACCINE**

Please circle your choice - I want my child to receive the FLU MIST (Nasal) or INJECTION

PAYMENT OPTIONS (listed below are the approved billable insurances)

Georgia Medicaid #______Amerigroup / Medicaid/ Peachcare/ Peachstate/ Wellcare

Blue Cross Blue Shield PPO ONLY Policy # ______

Policy Holder name ______Date of birth _____/______/______

Other Insurance Coverage not listed above feefor Vaccine or Mist will be $25.00 per person.

No Insurance Coverage- Adult Injectable Flu or Nasal Mist $25.00 /Child Injectable Flu or Nasal Mist $21.93

**Make check or Money orders Payable to Henry County Health Department **

Consent for Seasonal Influenza Vaccine

I have received the CDC vaccine information statement. I have had the opportunity to ask questions and understand the benefits and risks of the flu vaccine. I request and voluntary consent that the flu vaccine be given to the person above. I authorize the release of information from public health as required by law, for data collection and filing of claims for reimbursement directly from Medicaid or my insurance provider if applicable. I hereby release the school system, public health, participating nursing school, program and clinic volunteers from any and all liability.

Signature of Parent / Guardian: ______Print Name ______Date_____/____/____