Healthcare Flu Brochure

HEALTHCARE FLU BROCHURE

Patient Information

Date of Birth:    Gender:

Primary Phone:    Emergency Contact:   Phone:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

About Influenza and Vaccination

Influenza (flu) is a contagious respiratory illness caused by influenza viruses. Vaccination reduces the risk of infection and serious complications. Vaccine types include inactivated and recombinant formulations; the clinician will provide the vaccine recommended for the patient's age and health status.

Benefits: Vaccination lowers the chance of becoming ill, decreases severity if infection occurs, and reduces hospitalization and mortality in high-risk populations.

Common side effects include soreness at the injection site, low-grade fever, and myalgia. Serious allergic reactions are rare but can occur. Immediate medical attention will be provided in the unlikely event of a severe reaction.

Medical History — Please Complete

Have you ever had a severe allergic reaction to a vaccine or injectable medication?   Yes   No

Are you pregnant, breastfeeding, or planning pregnancy in the next month?   Yes   No

Contraindications and Precautions

Please indicate any of the following that apply to you by checking the box. These conditions may affect whether the vaccine should be given today.

History of severe allergic reaction to any component of the influenza vaccine or prior dose
Anaphylaxis following egg exposure (discuss with clinician)
Current moderate or severe illness with or without fever
History of Guillain-Barré syndrome within 6 weeks of prior influenza vaccination

Consent for Influenza Vaccination

I have read or had explained to me the information in this brochure regarding influenza and influenza vaccination. I have had the opportunity to ask questions and understand the potential benefits and risks described above.

I hereby:   Consent to receive the influenza vaccine today.    Decline the influenza vaccine at this time.

Privacy and Authorization

I acknowledge that I have been informed of the practice's privacy policies and that my protected health information related to vaccination may be used to administer care, to bill for services, and to report to public health authorities as required by law.

I authorize the release of relevant health information to the insurer named above for claims processing and to public health authorities for disease surveillance, immunization registries, and outbreak response as required by law. I understand this authorization expires on:

I understand that I may revoke this authorization in writing except to the extent that action has already been taken in reliance on it. I understand that revocation will not affect disclosures made prior to receipt of revocation.

Emergency Care and Reporting

If an immediate adverse reaction occurs, emergency medical care will be provided. Any serious adverse event following vaccination will be documented in the medical record and reported to appropriate public health authorities in accordance with legal reporting requirements.

Acknowledgment and Signature

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge, that I have read and understand the information contained in this brochure, and that I consent to the uses and disclosures described above where applicable.

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