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The Flu Vaccine Form is a comprehensive document designed to ensure the safe and effective administration of flu vaccines, tailored to the specific needs and health status of each individual. It begins with the necessary identification and insurance information, ensuring that vaccines are accessible to both insured and uninsured persons, including alternate identification for those without a traditional ID. The form extends into a detailed patient information section, where patients provide essential data including name, contact details, and demographic information, crucial for personalizing care and maintaining accurate medical records. A screening questionnaire follows, designed to identify any conditions or circumstances that might influence vaccine choice or necessitate a delay in vaccination, addressing concerns from basic health status and allergies to specific medical conditions and pregnancy. This ensures that patients receive vaccinations safely, with informed consent as a cornerstone of the process. Furthermore, the form facilitates the coordination of care by allowing information sharing with primary care providers and acknowledging the role of pharmacists in patient education and vaccine administration. It concludes with legal and procedural acknowledgements, including permissions for billing and information sharing with health registries and a summary of the patient's rights and consent to treatment, encapsulating the comprehensive, patient-centered approach to immunization.

Preview - Flu Vaccine Form

Insurance Card: ________________ ID: ___________________ Group: ______________

I do not have insurance

Identification must be provided for COVID Vaccine

 

Driver's License State___ #__________ State ID State___ #______________

I do not have ID

Screening Questionnaire and Consent Form

Patient Information: (Patient to complete)

Patient Name: ____________________________Date of Birth: _________ Age: _____ Phone#: ___________________

Address: ________________________________ City: ___________________________ State: ____ Zip: ____________

Email Address:_____________________________________________________________________________________

Gender: M or F Which vaccine(s) would you like to receive today?___________________________________________

Ethnicity: Hispanic or Latino(1)

Not Hispanic or Latino(2) Unknown(3)

Race: American Indian/Alaska Native(4)

Asian(3) Native Hawaiian/Other Pacific Islander(5)

Black or African American(1)

White(2)

Unknown(6)

Medical Conditions: ___________________________________________ Enter Weight if less than 110 lbs.: __________

**FOR EMERGENCY USE ONLY**

Primary Care Physician (PCP): _________________________________ Dr. Phone: _____________________________

PCP address- City ________________________________________ State______Zip Code _______________________

I authorize the pharmacist to send copies of my vaccine documents to my primary care provider. Yes � No �

Failure to select one of these boxes will result in the vaccine documents being sent to my primary care provider, if known, as state laws & regulations require for my state.

The following questions will help us determine which vaccines may be given today.

Yes

No

Don’t Know

If a question is not clear, please ask your pharmacist to explain it.

 

 

 

Are you sick today?

 

 

 

 

 

 

 

Do you have a long term health problem with heart disease, kidney disease,

 

 

 

metabolic disorder (e.g. diabetes), anemia or other blood disorders?

 

 

 

Do you have a long term health problem with lung disease or asthma? Do you smoke?

 

 

 

 

 

 

 

Do you have allergies to medications, food (i.e. eggs), latex or any vaccine component

 

 

 

(e.g. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin,

 

 

 

gelatin, baker’s yeast or yeast)?

 

 

 

Have you received any vaccinations in the past 4 weeks?

 

 

 

 

 

 

 

Have you ever had a serious reaction after receiving a vaccination?

 

 

 

 

 

 

 

Do you have a neurological disorder such as seizures or other disorders that affect the

 

 

 

brain or have had a disorder that resulted from a vaccine (e.g. Guillain-Barre Syndrome)?

 

 

 

Do you have cancer, leukemia, AIDS, or any other immune system problem?

 

 

 

(in some circumstances you may be referred to your physician)

 

 

 

Do you take prednisone, other steroids, or anticancer drugs, or have you

 

 

 

had radiation treatments?

 

 

 

During the past year, have you received a transfusion of blood or blood products,

 

 

 

including antibodies?

 

 

 

Are you a parent, family member, or caregiver to a new born infant?

 

 

 

 

 

 

 

For women: Are you pregnant or could you become pregnant in the next three months?

 

 

 

 

 

 

 

Did you bring your Immunization Record Card with you?

 

 

 

 

 

 

 

Are you currently enrolled in one of our medication adherence programs at Rite Aid

 

 

 

(OneTrip Refill, Automated Courtesy Refills, or Rx Messaging- Text, Email, Phone)?

 

 

 

Have you had the following vaccines:

Yes

No

Don’t Know

• Pneumococcal Vaccine-- *you may need two different pneumococcal shots*

 

 

 

• Shingles Vaccine

 

 

 

• Whooping Cough (Tdap) Vaccine

 

 

 

 

 

 

 

12-2020

I authorize the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid or other third party payer as needed and request payment of authorized benefits to be made on my behalf to Rite Aid.

-I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine.

-I acknowledge that my vaccination record may be shared with federal or state or city agencies for registry reporting.

-I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area, for 15 minutes, after the administration of the immunization.

-I acknowledge receipt of Rite Aid’s Notice of Privacy Practices for Protected Health Information.

-I acknowledge that the administration of an immunization or vaccine does not substitute for an annual check-up with the patient’s primary care physician.

-For CA: I acknowledge that Rite-Aid intends to share my vaccination record with the California Immunization Registry (CAIR) and that I have reviewed the ‘CAIR Immunization Notice to Patients and Parents’ attached to this form.

-For CA: I acknowledge that if I do not want my immunization information shared with other CAIR users, I must complete and submit to CAIR a “Decline or Start Sharing/Information Request Form” obtained either from the pharmacy or downloaded from the CAIR website (http://cairweb.org/cair-forms/).

-I certify my receipt of the services covered by this claim. I request that payment be made on my behalf. I authorize the holder to release medical information about me to any party involved in payment or their agents.

-I have read, or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s). I fully release and discharge Rite Aid Corporation, its affiliates, officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.

Patient Signature or legal guardian signature __________________________________________________________

If legal guardian print name _________________________________________________________________________

PHARMACY USE ONLY

o

Place RX Label Here

o

Place RX Label Here

Influenza Injectable

o

DTaP

Influenza Injectable

o

DTaP

o

Pneumococcal

o

Zoster (Shingles)

o

Pneumococcal

o

Zoster (Shingles)

o

Hepatitis B

o

Tdap

o

Hepatitis B

o

Tdap

o

HPV

o Hepatitis A & B

o

HPV

o Hepatitis A & B

o

Varicella

o

Other:

o

Varicella

o

Other:

o

IPV:

 

 

o

IPV:

 

 

o

Meningococcal

 

 

o

Meningococcal

 

 

o

Td

 

 

o

Td

 

 

o

Hepatitis A

 

 

o

Hepatitis A

 

 

o

MMR

 

 

o

MMR

 

 

Lot #______________________________

Lot #_______________________________

Exp. Date _________________________

Exp. Date___________________________

Site RA or LA- Circle One

Site RA or LA- Circle One

Clinic – Yes

No

 

Signature of pharmacist who administered Vaccine(s) and provided VIS to patient: __________________________________________

License #: ____________ NPI #: ______________ Date: _________

Signature of Certified Immunizing Technician or Intern who administered Vaccine(s): ________________________________________

Download Flu Vaccine PDF Form

Form Data

Fact Detail
Insurance Information Requirement Patients must provide their insurance card, ID, and group number if insured.
No Insurance Option There is an option for patients who do not have insurance.
ID Requirement for COVID Vaccine Identification such as a driver's license or state ID is necessary for COVID vaccine.
Patient Information Collection Form collects comprehensive patient information including contact details and medical history.
Vaccine Selection Option Patients can indicate which vaccine(s) they wish to receive.
Ethnicity and Race Information Patients are asked to provide their ethnicity and race.
Medical Condition Queries Patients are asked about existing medical conditions relevant to vaccine administration.
Consent for Information Sharing Authorization is required to send vaccine documents to primary care provider or appropriate parties.
Vaccination Record Sharing Consent is given for sharing vaccination records with federal, state, or city agencies for registry reporting.
California-Specific Acknowledgments For California residents, specific acknowledgments regarding CAIR are included.

Instructions on Utilizing Flu Vaccine

Filling out the Flu Vaccine Form is important for ensuring a safe and efficient vaccination process. This process involves providing personal information, answering health-related questions, and giving consent for the vaccination. The form might seem lengthy, but it's designed to collect necessary information to protect your health and adhere to legal requirements. Here's a step-by-step guide on how to fill out the form accurately.

  1. Start with your Insurance Information. Fill in the Insurance Card number, ID, and Group. If you do not have insurance, mark the appropriate option.
  2. Next, provide an applicable form of Identification. This could be a Driver's License or State ID. Fill in the state and number. If you do not have an ID, mark the corresponding option.
  3. Under the Screening Questionnaire and Consent Form, complete the Patient Information section. Include your full name, date of birth, age, phone number, complete address (including city, state, and zip code), and email address.
  4. Select your gender by marking either M (Male) or F (Female).
  5. Indicate which vaccine(s) you wish to receive today by writing them in the provided space.
  6. Answer the question about your ethnicity by choosing Hispanic or Latino, Not Hispanic or Latino, or Unknown.
  7. Select your race from the options provided.
  8. List any medical conditions you have in the provided space. If you weigh less than 110 lbs., enter your weight.
  9. Fill in your Primary Care Physician's (PCP) information including their name, phone number, and address.
  10. Grant or deny authorization for the pharmacist to send copies of your vaccine documents to your PCP.
  11. Answer the health screening questions to help determine vaccine eligibility.
  12. Provide information about your immunization history and whether you're enrolled in any medication adherence programs at the pharmacy.
  13. Acknowledge the consent statements at the bottom of the form by reading and understanding them. This includes consent to share your vaccination record and other related acknowledgements.
  14. Sign the form and, if you are a legal guardian filling it out for another person, print your name.
  15. For PHARMACY USE ONLY section, leave it blank as it will be completed by the pharmacy staff.

After completing the form, submit it to the pharmacy staff. They will review your information, answer any additional questions, and proceed with the vaccination process as appropriate. Remember, filling out this form accurately helps to ensure your safety and compliance with health regulations. If you have any questions while filling out the form, don't hesitate to ask the pharmacy staff for assistance.

Obtain Answers on Flu Vaccine

  1. What identification is required for receiving the flu vaccine?

    For individuals seeking to receive the flu vaccine, identification must be presented. Acceptable forms of ID include a driver's license or a state ID, with the necessity to provide the state and ID number. In cases where the vaccine administered is for COVID, additional identification verification is mandatory. It's important to note for patients without insurance, presenting identification is still a requirement.

  2. Can I receive a flu vaccine if I do not have insurance?

    Yes, individuals who do not have insurance can still receive the flu vaccine. However, it's essential to indicate on the form that you do not have insurance. The form includes a specific section where individuals can denote the absence of insurance coverage. Proper identification is still required for all individuals, regardless of their insurance status.

  3. What information do I need to provide on the Screening Questionnaire and Consent Form?

    The Screening Questionnaire and Consent Form requires several pieces of patient information, including the patient's name, date of birth, age, contact number, address, email, and gender. Additionally, patients are asked about their desired vaccines, ethnicity, race, medical conditions, and weight if it's less than 110 lbs. The form also includes a section for providing the primary care physician's details and medical history questions relevant to vaccine administration.

  4. What happens if I don't authorize the pharmacist to send my vaccine documents to my primary care provider?

    If no selection is made regarding the authorization for a pharmacist to send vaccine documents to the primary care provider, the documents will be sent to the patient's primary care provider if known. This action is in accordance with state laws and regulations, which typically require the sharing of vaccine information with healthcare providers to ensure proper patient care and record-keeping.

  5. What should I do if I have allergies to components commonly found in vaccines?

    If you have allergies to any medications, foods (such as eggs), latex, or any known vaccine component (e.g., neomycin, formaldehyde, gentamicin), it's crucial to indicate this on the Screening Questionnaire section of the form. This information helps healthcare providers determine the safety and suitability of administering a particular vaccine to you. Additionally, discuss any concerns or questions with your pharmacist or healthcare provider before receiving the vaccine to ensure it's safe given your medical history and allergies.

Common mistakes

When filling out the Flu Vaccine form, it's crucial to pay attention to the details to ensure a smooth and efficient vaccination process. However, some common mistakes can lead to unnecessary complications. Below are five key errors often made:

  1. Incomplete Patient Information: One of the most frequent missteps involves not filling out the entire patient information section. This includes leaving fields like "Patient Name," "Date of Birth," "Phone Number," and "Address" blank or partially filled. Ensuring that all fields are accurately completed is essential for proper record keeping and patient identification.

  2. Insurance Information Errors: Many individuals either forget to bring their insurance card to the vaccination site or fail to accurately transcribe the information onto the form. This includes the "Insurance Card ID," "Group Number," and neglecting to mark the "I do not have insurance" box if applicable. Accurate insurance details are vital for billing purposes.

  3. Incorrect Vaccine Selection: Occasionally, patients mark the wrong vaccine(s) they wish to receive. This section of the form requires careful attention to ensure that the intended vaccine is clearly indicated, helping avoid potential health risks or the need for a return visit due to incorrect vaccine administration.

  4. Failure to Acknowledge Consent and Authorizations: Some patients overlook the need to select "Yes" or "No" in response to authorizing the pharmacist to send vaccine documents to the primary care provider. In states where laws and regulations apply, failing to make a selection can automatically result in documents being sent. It's also crucial to sign at the bottom of the form to officially consent to the vaccination and verify understanding of and agreement with the information provided.

  5. Omitting Medical History and Allergies: Often, individuals might skip the sections that inquire about medical conditions, allergies to medication, foods, latex, or any vaccine component, and whether they've received vaccinations in the past 4 weeks. This information is critical in determining vaccine eligibility and the potential for adverse reactions.

Avoiding these errors can significantly enhance the vaccination process's safety, efficacy, and efficiency. Patients are encouraged to read the form thoroughly, ask questions if any section is unclear, and verify that all their responses are complete and accurate before submission.

Documents used along the form

When an individual decides to receive a flu vaccine, a series of forms and documents are often involved in complementing and facilitating the process in a healthcare setting. These documents ensure an organized, compliant, and comprehensive approach to patient care and medical recording. From consent forms to insurance information, each document plays a crucial role in ensuring the vaccination process is smooth, informed, and aligned with regulatory guidelines.

  1. Insurance Information Form: This document collects the patient's insurance details, including provider name, policy number, and group number, ensuring the vaccination costs are appropriately billed to the right party.
  2. Identification Document Copies: Such as copies of the driver's license or state ID, these validate the patient's identity, preventing medical identity fraud and ensuring accurate patient records.
  3. Screening Questionnaire and Consent Form: This form assesses the patient's health and suitability for vaccination. It also serves as a legal agreement where the patient consents to receive the vaccine after being informed of its benefits and risks.
  4. Patient Information Sheet: A document that records fundamental patient details, including name, address, and contact information, ensuring healthcare providers have a means to follow up or make necessary contacts post-vaccination.
  5. Privacy Notice Acknowledgment: Confirms that the patient has received and understood the notice of privacy practices, as mandated by healthcare regulations, ensuring patients are aware of their rights concerning their personal health information.
  6. Vaccination Information Statement (VIS): Provided by the CDC, this informs the patient about the specific vaccines they are receiving, the diseases they prevent, potential side effects, and what to do in the event of a reaction.
  7. Immunization Record Card: A personal record for patients to keep track of all their vaccinations over time, facilitating continuity of care and compliance with school, work, or international travel requirements.
  8. Medication Adherence Programs Enrollment Form: For those who are part of pharmacies' adherence programs, this document records consent and enrollment in services that assist in managing medication schedules, including vaccinations.

Together, these documents not only support the administrative and clinical aspects of vaccination but also contribute to the overall healthcare journey of an individual, ensuring safety, accountability, and patient empowerment. By meticulously collecting and managing these documents, healthcare providers can offer superior care, meet regulatory demands, and foster a trusting relationship with their patients.

Similar forms

  • COVID-19 Vaccine Consent Form: This document is similar to the Flu Vaccine form in structure and content. It captures patient identification details, health insurance information, and a screening questionnaire, including medical history and current health status. Both forms require the patient's (or legal guardian's) consent for vaccination and have provisions for documenting vaccine specifics such as type and lot number.

  • General Medical Consent Form: The elements of documenting patient information, health status, and consent found in the Flu Vaccine form resemble those in a general medical consent form. This form differs primarily in scope, covering a broader range of medical procedures beyond vaccinations. However, both serve to inform patients of their medical choices and collect their authorization.

  • Immunization Record Card: While an Immunization Record Card itself is not a consent form, its content aligns with the vaccination documentation portion of the Flu Vaccine form. Both track the type of vaccines administered, including lot numbers and dates, serving as a personal medical record for the patient.

  • Pharmacy Medication Consent Form: These forms share similarities with the Flu Vaccine form since both include patient identification, insurance details, and the acknowledgment of information related to the medical service provided — in this case, vaccinations or medication therapy. They ensure the patient or guardian understands the service and agrees to it.

  • Travel Vaccination Consent Form: Similar to the Flu Vaccine form, this type of document is specifically designed for vaccinations, with a focus on travel-related immunizations. It collects comprehensive patient data, health and vaccine history, and includes a section for informed consent specifically tailored to vaccines recommended or required for travel to certain destinations.

Dos and Don'ts

When it comes to filling out a Flu Vaccine form, it's important to approach the task with care and attention. Below is a list of do's and don'ts that can help ensure the process is completed correctly and efficiently.

Things You Should Do:

  1. Double-check the information required on the form, such as your Insurance Card details, ID, and Group number, to ensure accuracy.

  2. Fill out the Screening Questionnaire and Consent Form thoroughly, providing detailed and honest answers about your medical conditions and vaccination history.

  3. Bring along your Identification and Insurance Card to the clinic, as proof of identity and insurance cover are often required for the vaccination.

  4. Make a note of your Primary Care Physician’s contact details, so the pharmacist can forward your vaccine documents if necessary.

  5. Consider your vaccine options carefully, and indicate clearly which vaccine(s) you wish to receive.

  6. Read the Vaccination Information Sheet (VIS) provided to you, to fully understand the benefits and risks associated with the vaccine(s).

  7. Sign the consent form to authorize the release of medical information and acknowledge the receipt of the vaccine.

Things You Shouldn't Do:

  1. Avoid leaving sections blank. If a section does not apply to you, fill in with "N/A" or check the appropriate box if provided.

  2. Do not forget to check off whether you authorize the pharmacist to communicate with your Primary Care Physician.

  3. Do not overlook the importance of indicating any allergies or medical conditions that could affect your vaccine choices.

  4. Refrain from signing the consent form without understanding what you are agreeing to. If something isn’t clear, ask questions.

  5. Don't ignore the recommended waiting period in the clinic after receiving your immunization, as this is for your safety.

  6. Avoid providing incomplete or false information about your health status, as this could have serious implications.

  7. Do not forget to bring your Immunization Record Card, if available, for the pharmacist’s reference.

Following these guidelines can help ensure a smooth and safe vaccination process, contributing to effective disease prevention and promoting public health.

Misconceptions

When it comes to the flu vaccine, there's a substantial amount of misinformation that can lead to hesitancy and confusion. Debunking common misconceptions is crucial for informed healthcare decisions. Here are seven widespread myths and their explanations:

  • The flu vaccine can give you the flu. This is perhaps the most prevalent misconception. The flu vaccine is formulated with dead viruses or without the flu virus at all (in the case of recombinant vaccines). These components are incapable of causing the flu. Some individuals may experience mild side effects, such as soreness at the injection site or a low-grade fever, but these symptoms are not the flu and are generally short-lived.

  • It's better to get the flu than the vaccine. This perspective underestimates the severity of the flu. Every year, the flu causes numerous hospitalizations and deaths. The flu vaccine is a safe and effective way to protect not just oneself but also vulnerable populations from severe illness.

  • Healthy people don't need the flu vaccine. While it's true that some people are at higher risk for serious flu complications, including the elderly, very young children, and those with certain chronic conditions, even healthy individuals can benefit from the vaccine. The flu can be severe and lead to hospitalization even in healthy people, and vaccination also helps protect those around you.

  • You don’t need a flu vaccine every year. The flu virus mutates and evolves rapidly, meaning last year’s vaccine may not protect against this year’s viruses. Annual vaccination is recommended to ensure protection against the most currently circulating strains.

  • If you're pregnant, you shouldn't get the flu vaccine. On the contrary, it's highly recommended for pregnant individuals to receive the flu vaccine. Pregnancy alters the immune system, heart, and lungs, making the flu more likely to cause serious illness that could affect both the mother and the baby. The vaccine is safe during any stage of pregnancy.

  • The flu vaccine can cause autism. Studies have repeatedly shown that there is no link between receiving vaccines and developing autism. This myth, based on a fraudulent study, has been debunked thoroughly over the years.

  • If you've missed the flu season's start, there's no point in getting vaccinated. While it’s best to get vaccinated before the flu season begins, receiving the vaccine later can still be beneficial. Flu season can last into the spring, and since the vaccine takes about two weeks to become effective, getting vaccinated later can still provide protection.

Critical assessment of information and sources can help dispel these myths, promoting a healthier and more informed public.

Key takeaways

When filling out and using the Flu Vaccine form, it's crucial to keep the following key takeaways in mind:

  • Ensure all personal information is accurate and complete, including your full name, date of birth, and contact details. This information is essential for the vaccination record and any necessary follow-ups.
  • Provide detailed insurance information if available. If you are insured, filling in your insurance card details, ID, and group number is necessary to potentially cover the cost of the vaccine. It's also important to declare if you don't have insurance, as there might be alternate provisions for your vaccination.
  • It is mandatory to answer the Screening Questionnaire honestly. The questions aim to identify any health conditions or allergies that could affect the type of vaccine you should receive or if you should receive one at all.
  • Authorization to send vaccine documents to your primary care provider is given by default unless you explicitly refuse. This ensures your health records are up-to-date and your healthcare provider is informed of your vaccination.
  • After receiving the vaccine, you are advised to stay in the waiting area for 15 minutes. This precaution is recommended to monitor any immediate adverse reactions to the vaccine, ensuring your safety. Also, acknowledging receipt of the Vaccination Information Sheet (VIS) and understanding its content is crucial before giving your consent for vaccination.

Additionally, always remember to bring any relevant medical documents, such as your Immunization Record Card, and inform the pharmacist about any medication adherence programs you are part of. This comprehensive approach ensures a smooth, safe, and efficient vaccination process.

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