Flu / Pneumonia Consent Form

I have read or have had explained to me the information on the VIS form. I have had a chance to ask questions, which were answered to my satisfaction. I believe I understand the benefits and risks of the pneumococcal and/or influenza vaccine and request that the vaccine be given to me or to the person named below for whom I am authorized to make this request. If I have Medicare or Medicaid (Jasper County Health Department can only bill Medicaid for this service for individuals 18 years of age and younger), I authorize billing for this injection. I understand that if Medicare or Medicaid denies to pay for this service, I am responsible for payment.

Date of Immunization:____________________________        Flu______           Pneumonia______

(Must be exactly as it appears on your Medicaid or Medicare card)

Last Name_____________________________ First Name_____________________ Middle Initial_________

Address:_______________________________ City____________ State_______________ Zip Code_______

Date of Birth:_________________ If child - Age_______ Male___ Female___ Phone Number:________________

Choose Method of Payment:

Medicare Number:________________ Medicaid Recipient Number:_________________ Cash/Check_________

Signature:__________________________________________

* Must be completed the day of the vaccination:

1. Are you feeling well today? Yes___ No___

2. Are you allergic to chicken/egg products? Yes___ No___

3. Have you ever had Guillain-Barre Syndrome? Yes___ No___

4. Have you ever had a reaction to a flu shot? Yes___ No___

5. If you are female, are you pregnant? Yes___ No___ N/A___

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For office use only: Business to bill to:_____________________              Flu: Lot # Pneumonia: Lot:

 Nurse_____________________             L R Deltoid       VIS_____       Expiration Date:                      Expiration Date:

                                                                Manufacturer: Aventis Manufacturer: