Reception __________ Central Reg _________
School Clinic Annual Flu Vaccine Consent Form Return to school one week prior to clinic date Section 1: Information about Child to Receive VaccinePlease Print
Student’s Date of Birth Month______ Day_______ Year________
Student’s Doctor’s Name (Last, First) Address City Zip School Name
Section 2: Insurance Information _____Injection (shot) _____ Nasal Spray Section 3: Screening for Vaccine EligibilityPlease mark YES or NO for each question. YES NO
Has your child been vaccinated with the seasonal influenza vaccine after July 1, 2010?
Does your child have a serious allergy to eggs?
Does your child have any other serious al ergies? Please list:______________________________
Has your child ever had a serious reaction to a previous dose of flu vaccine?
Has your child ever had Guillain-Barŕe Syndrome (temporary severe muscle weakness) within 6
weeks after receiving a flu vaccine? Has your child gotten vaccinated with any vaccine (not just flu) within the past 30 days? Vaccine____________________________ Date Given: Month_______ Day_________ Year______
Does your child have any of the following: Asthma, Diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves, or blood?
Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)?
Does your child have a weak immune system (for example, from HIV, Cancer, or medications such as steroids or those used to treat cancer)?
Was your child started on Antiviral medication before the scheduled vaccination clinic?
Section 4: Consent for Child’s Vaccination: I have read or had explained to me the 2012-2013 Vaccine Information Statement for the seasonal influenza vaccine and understand the risks and benefits. I give consent to ACMC and its staff/volunteers for my child named at the top of this form to be vaccinated with this vaccine. Your signature below is required in order to vaccinate your child. Signature of Parent/Guardian___________________________________________Date:_____________
MINNESOTA VACCINES FOR CHILDREN PROGRAM (MnVFC) PATIENT ELIGIBILITY SCREENING RECORD Children 18 years of age or younger Your child qualifies for vaccination through the MnVFC program because he/she: Please MnVFC Eligibility Criteria
Enrol ed in MNHealthcare Program (MA, PMAP, GAMC, MnCare)1
*Underinsured patients are no longer eligible for MNVFC. Please check your insurance for coverage, you
may be billed. You may also receive your vaccinations at local public health immunizations clinics.
FOR ADMINISTRATIVE USE ONLY Section 5: Vaccination Record Date Dose Injection Route & Dose Lot Number Administered Manufacturer
Name and Title of Vaccine Administrator:
POLYCYSTIC OVARY SYNDROME N -acetyl-cysteine is a novel adjuvant to clomiphene citrate in clomiphene citrate–resistant patients with polycystic ovary syndrome Ahmed Y. Rizk, M.D., a Mohamed A. Bedaiwy, M.D., b and Hesham G. Al-Inany, M.D. ca Department of Obstetrics and Gynecology, Benha University, Benha; b Department of Obstetrics and Gynecology AssiutSchool of Medicine, Assiut; a
Osteoarthritis of the Shoulder The main joint in the shoulder is called the glenohumeral joint. It commonly is thoughtof as the 'ball and socket' joint of the shoulder, but is actually more of a ball and saucer,as the bony socket is more flat than cup shaped. There normally is a very smoothcovering of cartilage over the bones in the joint that allows normal, smooth and pain
Reception __________ Central Reg _________
School Clinic Annual Flu Vaccine Consent Form 
Was your child started on Antiviral medication before the scheduled vaccination clinic?