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
6. Telephone Number________________________________ (during the day)
The following questions will help us determine if there is any
reason we should not give you or your child injectable influenza
vaccination today. If you answer “yes” to any question, it does not necessarily mean you
(or your child) 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 sick today?
2. Do you have any allergies?
3. Do you have an allergy to eggs or to a
component of the vaccine?
4. 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: ______________________________
Clerical Nurses Nurses/Clerical Biller
Demo/Ins____________ (Init) CureMD Note _________ (Init) NCIR ___________ (Init) Billed ________(Init)
Date __________ Date __________ Date ___________ Date ________