Immunization Consent

NYC Docs : Immunization Consent

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Influenza/ Pneumococcal Immunization Consent Form

The Influenza/Pneumococcal Immunization Consent Form provided by NYCDocs is a record-keeping tool to maintain your accurate and up-to-date health records. It helps the primary care physicians in Bronx to access your previous vaccination history. So that they can provide you with the appropriate vaccines. By this consent form you become aware of the vaccinations that have been administered on you.

Preferred Location *

Last Name^*

First Name^*

Date of Birth^*

Sex^*

Male

Female

Phone^*

County of Residence

Address

City

State

Zip

For Persons Under 19 Years Old, Mother’s Maiden Name

Medicare Claim Number

Doctor’s Name

Health Insurance Provider

Doctor’s Address

Policy Number

NYSIIS Permission ≥ 19 Years Old

Yes

Clinic/Office Site Where Vaccine Administered

Please complete the questions below for yourself or the person receiving the vaccine.

YES NO	Are you currently sick with a fever?
YES NO	Have you ever had a life threatening allergy to any component (or part) of the flu or pneumonia vaccine? If yes, please describe:
YES NO	Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving flu vaccine?
YES NO	Have you ever had a pneumonia shot?
YES NO	Are you a smoker or have a chronic medical condition such as asthma, heart or lung disease? If yes, please describe:
YES NO	Have you ever had a severe life threatening allergy to eggs or egg products?
YES NO	Are you currently pregnant?
YES NO	Do you have a history of asthma or wheezing?
YES NO	Are you a child or adolescent receiving long-term aspirin therapy?
YES NO	Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care?
YES NO	Have you received any other vaccinations within the last 4 weeks?
YES NO	Have you taken an antiviral medication for the flu within the last 48 hours?

Influenza Consent

I have read, or had explained to me, the Vaccine Information Statement about influenza vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. Irequest that the influenza vaccination be given to me (or the person named above for whom I am authorized to make this request). I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights.

Signature of Recipient (Parent or Guardian)

Date

Pneumococcal Consent

I have read, or had explained to me, the Vaccine Information Statement about pneumococcal vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. I request that the pneumococcal vaccination be given to me (or the person named above for whom I am authorized to make this request). I authorize the release of any medical or otherinformation necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights.

Signature of Recipient (Parent or Guardian)

Date

For over 15 years, NYCDocs's top-rated primary care physicians in New York have prioritized patient comfort and needs, offering exceptional medical healthcare services.

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