Southparkpediatrics.net

2009 H1N1 Influenza Vaccine Consent Form
Section 1: Information about Person to Receive
DATE OF BIRTH
Vaccine (please print) NAME (Last)
month_________
day________
year __________
PARENT/LEGAL GUARDIAN’S NAME (Last)
Male / Female
PHONE NUMBER:
HISPANIC? YES NO
SOCIAL SECURITY #:
MARITAL
STATUS

Section 2: Screening for Vaccine Eligibility
If you/your child has already been vaccinated with 2009 H1N1 influenza vaccine, please tell us the number of doses and dates of vaccination.
Dose 1 Date received: month ____day____year_______ Form (please circle): nasal spray shot
Dose 2 Date received: month ____day____year_______ Form (please circle): nasal spray shot

The following questions will help us to know if you/your child can get the 2009 H1N1 influenza vaccine. Mark YES or NO for each question.
A. If you answer “NO” to all four of the following questions, you/your
child can probably get the influenza vaccine. If you answer “YES” to one
or more of the following four questions, your child may be able to get the
2009 H1N1 vaccine, but we may need to ask you more questions.
1. Does your child have a serious allergy to eggs? Yes_____ No_____
2. 2. Does your child have any other serious allergies including gentamicin, MSG,gelatin, arginine? Yes____No____Please list: ________________________ 3. 3. Has your child ever had a serious reaction to a previous dose of flu vaccine? Yes_____ No_____ 4. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) within 6 weeks of receiving a flu vaccine?Yes_No_ B. There are two kinds of 2009 H1N1 influenza vaccine. Your answers to the following
questions will help us know which of the two kinds of vaccine your child can get.
1 1. Has your child been vaccinated with any vaccine (not just flu) within the past 30 days? Yes_____ No_____ Shot?_____Nasal?_____ Vaccine: ___________________________________ Date given: month______day_______year___________ 2. Has your child taken any anti-viral medications in the last 48 hours? Yes_____ No_____ 3. Does your child have any of the following: asthma, diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves (seizures, hypotonia,Down’s syndrome), or blood? Yes_____ No_____ 4. Has your child younger than 5 years old experienced recurrent wheezing requiring albuterol, xopenex, or nebulizer therapy? Yes_____ No_____ 5. Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)? Yes_____ No_____ 5. 6. Does your child have a weak immune system (for example, from HIV, cancer, or medications such as steroids or those used to treat cancer)?Yes___No__ 7. Is your child pregnant? Yes_____ No_____ 7. 8. Does your child have close contact with a person who needs care in a protected environment (for example, someone who has recently had a bone marrow 7. 9. Have you read the information from the American Academy of Pediatrics on Thimerosal in Vaccines and had your questions answered?Yes___ No____ Section 3: Consent CONSENT FOR VACCINATION:
I have read or have had explained to me the information on the information form about H1N1 influenza vaccine. I have had a chance to ask
questions which were answered to my satisfaction. I believe I understand the risks and benefits of H1N1 influenza vaccine and request that
the H1N1 influenza vaccine be given to me or the person named above for whom I am authorized to make this request. I have been provided
access to the SouthPark Pediatrics Notice of Privacy Practices. I agree for Medicare, Medicaid and/or Insurance, if applicable, to be billed and
I authorize the release of any medical information necessary to process this claim. I authorize payment of medical benefits to the SouthPark
Pediatrics, PA.
Signature of Client/Parent/Legal Guardian _________________________________________ Date: ________________________

Section 4: Vaccination Record FOR ADMINISTRATIVE USE ONLY
Dose Number
Date Dose
Manufacturer/ Lot
Name and Title of
(1st or 2nd)
Administered
Vaccine Administrator
STATE/MEDICAID / INSURANCE / MEDICARE Number ___________________________________________________________ Name as Listed
_________________________________________________________ Effective / Valid Date(s) _____________________________________________
Vacc. Proc. Code 90663 G9142 (Medicare) Diagnosis V04.81 flu only
Admin. Proc. Code 1 injectable - 90471 1 intranasal - 90473 Both inj. and intranasal – 90471 and 90474 G9141 (Medicare)
ADD EP modifier when billing for Medicaid recipients from birth through 20 years of age. Sec. Initials______________________Sp3/clinical nurse binder/immunizations/11-09

Source: http://southparkpediatrics.net/images/H1N1_Consent_Form_110509.pdf