Site: __________________
1. Last Name____________________________ First Name_______________________ MI___
2. Date of Birth______________________
3. Race: White Black Am. Ind. /Alaskan Native Asian/Pacific Islander
4. Sex: Male Female Ethnicity: Hispanic Origin? Yes No
Mother’s Full Maiden Name ______________________________________________________
PLEASE COMPLETE MAILING INFORMATION IF DIFFERENT ON ID
5. Address______________________________________________________________________
6. Telephone Number_________________________ (during the day)
For adult patients 65 or over to be vaccinated: The following
questions will help us determine if there is any reason we should not give you injectable influenza
vaccination today. If you answer “yes” to any question, it does not necessarily mean you should
not be vaccinated. It just means additional questions must be asked. If a question is not clear,
please ask your healthcare provider to explain it.
Yes No Don’t Know
1. Are you 65 or over?
2. Are you sick today?
3. Do you have any allergies? If so, please list:
4. Do you have an allergy to eggs or
to a component of the vaccine?
5. Have you ever had a serious reaction to
influenza vaccine in the past?
STATEMENT OF PERMISSION AND ASSIGNMENT: By placing my initials in the space(s)
provided, I voluntarily give my permission to receive (initials) _______ influenza vaccine. I
understand that payment for this service may be made in accordance with the provisions of Title
XVIII of the Social Security Act (Medicare) and/or Title XIX of the Social Security Act (Medicaid);
and/or private insurance of other third-party payor. I hereby authorize the provider of service to
release information necessary for the processing of any claim for payment made on my behalf, and
I authorize payment to the provider for such claim. We will file your insurance and you will be
responsible for any co-pays, deductibles or non-covered charges.
___________________________________________ _____________________
Patient Signature Date
For Provider Use Only:
Cure MD Acct: _______________
Influenza Vaccine Mfgr/Lot # ____________________
Injection Site: ________Right ________ Left Deltoid
Administered by: ______________________________
Date: ________________
Clerical Nurses Nurses/Clerical Biller
Demo/Ins____________ (Init) CureMD Note _________ (Init) NCIR ___________ (Init) Billed ________(Init)
Date __________ Date __________ Date ___________ Date ________
Paid _____________
