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INFLUENZA (FLU), PNEUMOCOCCAL, & TETANUS (Td) VACCINE

REGISTRATION FORM/CONSENT 2011-2012 INFLUENZA SEASON

SUSSEX COUNTY DEPARTMENT OF ENVIRONMENTAL AND PUBLIC HEALTH SERVICES OFFICE OF PUBLIC HEALTH NURSING

PLEASE PRINT CLEARLY

Clinic date: __________________ Municipality code of residence: __________________ County Employee

NAME (last, first) STREET CITY PHONE DATE OF BIRTH MEDICARE # or MEDICAID # E-MAIL ADDRESS

*I give Sussex County Public Health Nursing my permission to bill Medicare or Medicaid for eligible benefits related to this service. My Medicare or Medicaid number will be used for billing purposes only. *I understand that there will be no charge to me if Medicare/Medicaid does not pay. *My medical information will be protected confidentially per HIPAA regulations.

County Department: STATE SEX: AGE ZIP Male Female ________________

Volunteer/ EMS/MRC

(include all letters) (BRING YOUR MEDICARE CARD WITH YOU)

__________

Forms reviewed by Your signature for Medicare/Medicaid

PRE-IMMUNIZATION QUESTIONNAIRE (Print form to answer the following questions) Are you allergic to eggs or egg products? Are you allergic to Thimerisol? (a preservative in some vaccines) Are you allergic to latex? Have you ever had a serious vaccine reaction after receiving a vaccination? · If yes, please describe: Are you sick today or have you been sick within the past 24 hours? · If yes, please describe: Have you ever had a seizure (convulsion), brain, or nervous system problem? (PHN note) Have you ever had a paralytic illness called Guillain-Barre Syndrome? YES NO · If yes, was it after receiving a flu, pneumonia, or tetanus vaccine? Have you ever had a FLU vaccine in the past? Did you have a FLU vaccine last year? Have you ever had a PNEUMONIA vaccine? · If yes, what year did you receive it? _______________ · Were you 65 or older when you received it? YES NO Have you had a TETANUS shot within the past 10 years? Do you have any of the following diseases or conditions?

The CDC guidelines recommend that people 2 through 64 years old receive a pneumonia vaccine if they have any of the following long-term health conditions: Alcoholism Disease or condition that lowers your body's resistance to infection, such as Diabetes mellitus Hodgkin's disease, lymphoma, leukemia, kidney failure, multiple myeloma, Heart Disease HIV/AIDS, damaged spleen or no spleen, organ/bone marrow transplant, Liver disease/cirrhosis generalized malignancy, nephrotic syndrome, sickle cell disease Leaks of cerebrospinal fluid Taking drugs or treatment that lowers your body's resistance to infection, Lung disease/COPD/asthma such as long-term steroids, certain cancer drugs, radiation x-ray therapy emphysema Cochlear implant (for hearing) The CDC guidelines recommend that adults 19 through 64 years of age receive a pneumonia vaccine if they Smoke cigarettes Have asthma

YES YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO NO

YES YES

NO NO

PUBLIC HEALTH.........PREVENT, PROMOTE, PROTECT

CONSENTS FOR VACCINATIONS 2011-2012

INFLUENZA VACCINE (Flu vaccine)

I received and read the information about Influenza disease, the vaccine, and special precautions. I have had the opportunity to ask questions that have been answered to my satisfaction. I verify that my answers on the Pre-Immunization Questionnaire are correct to the best of my knowledge.

INFLUENZA VACCINATION CONSENT

I understand the benefits and risks of the influenza vaccine as described. I request that the influenza vaccine be administered to me or to the person named for whom I am authorized to sign.

Signature:

Manufacturer/lot # of vaccine Signature of administrator

PNEUMOCOCCAL VACCINE (Pneumonia vaccine)

I received and read the information about Pneumococcal disease, the vaccine, and special precautions. I have had the opportunity to ask questions that have been answered to my satisfaction. I verify that my answers on the Pre-Immunization Questionnaire are correct to the best of my knowledge.

PNEUMOCOCCAL VACCINATION CONSENT

I understand the benefits and risks of the pneumococcal vaccine as described. I request that the pneumococcal vaccine be administered to me or to the person named for whom I am authorized to sign.

Signature:

Manufacturer/lot # of vaccine Signature of administrator

TETANUS VACCINE (Td vaccine)

I received and read the information about Tetanus disease, the vaccine, and special precautions. I have had the opportunity to ask questions that have been answered to my satisfaction. I verify that my answers on the PreImmunization Questionnaire are correct to the best of my knowledge.

TETANUS VACCINATION CONSENT

I understand the benefits and risks of the tetanus vaccine (Td) as described. I request that the tetanus vaccine (Td) be administered to me or to the person named for whom I am authorized to sign.

Signature:

Manufacturer/lot # of vaccine

G:\Public\Flu\2011\fluconsent2011-2012a

Signature of administrator

Information

INFLUENZA (FLU), PNEUMOCOCCAL, & TETANUS (Td) VACCINE

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INFLUENZA (FLU), PNEUMOCOCCAL, & TETANUS (Td) VACCINE