The completion of this form is necessary for every vaccine ...
The completion of this form is necessary for every vaccine recipient. If no insurance information is available, please fill out as much as possible using existing information.
Information about the person to receive vaccine (please print): *Required Fields
|Name: (Last, First, MI)* |Date of birth: * |Age* |Sex: (Circle)* |
| |_____ ____ _____ | |Male Female |
| |Month Day Year | | |
|Street Address:* |
|City:* |State: * |Zip:* |Phone:* |
| | | |( ) |
Insurance Information: Include the whole member ID number and any letters that are part of that number
|Name of Insurance Company:* |Member ID Number:* |Group ID Number: (if available) |
|Medicare Number: |Is Medicare Primary? |Is Subscriber Retired? |
| |Yes No |Yes No |
Insurance subscriber/policy holder, please complete the following:
|Subscriber’s Name: (Last, First, MI)* |Subscriber’s Date of Birth: * |Sex: (Circle)* |
| |_____ ____ _____ |Male Female |
| |Month Day Year | |
|Subscriber’s Street Address:* (If different from address above) |
|City:* |State:* |Zip: * |Phone:* |
| | | |( ) |
|Patient Relationship to Subscriber: (Circle)* Spouse Child Other |
I have been given a copy and have read and/or had explained to me the 2019-2020 Seasonal Influenza Vaccine Information Statement and understand the risks/benefits. I give permission for vaccine administration, for my insurance company to be billed and entry/sharing of this information in the Massachusetts Immunization Information System (MIIS).
X ______ Date: ________________
(Signature of patient, parent or legal guardian)
*************************************************************************************************************************************
Please complete this section for children 18 years of age and younger:
[pic]
**************************************************************************************************************************
For Clinic/Office Use Only:
Date of
ServiceVax
TypeVaccine
MfgrLot NoExp DateDose (mL) State
Supplied
Preserv
FreeInjection Route
Injection Site
(Circle)Date
On
VISDate VIS
GivenccIIV4Seqirus
(Flucelvax)
261200
06/21/2020
0.5
Yes
Yes
IMR Arm L Arm
R Leg L Leg
08/15/2019IIV4Flulaval
(GSK)MB9YJ
06/06/2020
0.5
Yes
Yes
IMR Arm L Arm
R Leg L Leg
08/15/2019IIV4Sanofi Pasteur
(Fluzone)
0.5
No
Yes
IMR Arm L Arm
R Leg L Leg
08/15/2019IIV40.5IMR Arm L Arm
R Leg L Leg
08/15/2019
IIV4 = Inactivated Influenza Vaccine, Quadrivalent
ccIIV4 = cell cultured inactivated influenza Vaccine, Quadrivalent
Signature of Vaccine Administrator:
_______________________________________
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