Student tdap registration form

COLUMBUS PUBLIC HEALTH IMMUNIZATION CLINIC
STUDENT INFLUENZA REGISTRATION FORM

STUDENT’S BASIC INFORMATION
Name of Student: ______________________________________________________________________________ Sex:
Name of Legal Guardian: _________________________________________________ Student’s Date of Birth: ________/________/____________ Street Address: ____________________________________________________________________________________ City: _________________________________________ Home Phone #: __________________ Cell Phone #: _____________________ Does the student consider himself/herself Hispanic or Latino? Which category best describes the race of the student? (Please select all that apply) Native Hawaiian or Pacific Islander BILLING INFORMATION Insurance Information: Other: _______________________________________________________ Information from insurance card: Subscriber ID or member #: ________________________________ Group #: _____________________________ Phone #: ___________________________ Claims address: ___________________________________________________________________ The student does not have health insurance (sign here for hardship waiver) I am unable to pay for services rendered: _______________________________________________________________________________________ 1. Is the student to be vaccinated sick today? 2. Did the student receive 2 or more doses of the seasonal influenza vaccine since July1, 2010? (If unsure mark No) 3. Does the student have an allergy to eggs, or to any other component of the influenza vaccine (Including polymyxin, neomycin, 4. Has the student ever had a serious reaction to influenza vaccine in the past? 5. Has the student ever had Guillain-Barré syndrome? 6. Does the student to be vaccinated have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder? 7. If the student is a child age 2 through 4 years, in the past 12 months, has a healthcare provider ever told you that he or she 8. Does the student to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune system problem; or, in the past 3 months, have they taken medications that weaken the immune system, such as cortisone, prednisone, other steroids, or anticancer drugs; or have they had radiation treatments? 9. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)? 11. Has the student received other live-virus vaccines (MMR, chickenpox) in the past 4 weeks? 12. Is the student taking antiviral medications? (e.g., amantadine, rimantadine, zanamivir, oseltamivir) I have read and understand the information about influenza and influenza vaccine. I have had a chance to ask questions. I understand the benefits and risks of influenza vaccination and ask that the vaccine be given to me or the person named above for whom I am authorized to sign. I GIVE CONSENT FOR MY CHILD NAMED AT THE TOP OF THIS FORM TO GET
VACCINATED FOR ONE OR TWO DOSES AS NEEDED. I also understand that any care received outside Columbus Public Health (e.g., referred care) wil not be paid for by Columbus
Public Health. I authorize the release of medical information necessary to process this claim for bil ing. I understand I may be bil ed for my co-pay and for any charges not covered by insurance or grants, unless I sign the hardship waiver above. I understand that the Privacy Notice of Columbus Public Health is available on the internet at: publichealth.columbus.gov/Asset/iu_files/HIPAA_Privacy_Notice.pdf. I can also have it mailed to me by calling 614-645-2738.
Parent/Legal Guardian Signature: _______________________________________________________________ Date_______/______/________

DO NOT WRITE BELOW THIS LINE - Health Department Use Only
Staf Screener Signature: __________________________________ Manufacturer:____________________________________________ Nurse Signature: __________________________ STUDENT 2ND INFLUENZA DOSE - Health Department Use Only – Do not write below this line Staff Screener Signature: __________________________________ Manufacturer:____________________________________________ Nurse Signature: ________________________________ Date: ____/____/______ C olumbus Public Health Immunization Clinic
240 Parsons Ave, Columbus OH 43215 • Phone (614)-645-7945 •

Source: http://sjms.net/assets/Student-Flu-Registration-Form-2013-14.pdf