NEW YORK STATE DEPARTMENT OF HEALTHBureau of Immunization Influenza/Pneumococcal Immunization Consent FormRM_StatsPersonal/Patient InformationFirst Name *Last Name *Date of Birth *Sex *Select an optionMaleFemaleAddress Address Line 1 * Address Line 2 City * State or Region Alabama Alaska Arizona Arkansas Armed Forces America Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State or Region * Country Zip * Phone *Email *Is the Patient Being Vaccinated under the age of 19? Yes No Mother's Maiden NameInsurance/Doctor InformationMedicare Claim NumberDoctor's NameDoctor's Address Address Line 1 Address Line 2 City State or Region Alabama Alaska Arizona Arkansas Armed Forces America Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State or Region Country Zip Health Insurance ProviderInsurance Policy NumberNYSIIS Permission > 19 Years Old Yes No Clinic/Office Site Where Vaccine AdministeredPlease complete the questions below for yourself or the person receiving the vaccine.Are you currently sick with a fever? * Yes No Have you ever had a life threatening allergy to any component (or part) of the flu or pneumonia vaccine? * Yes No If yes, please describe:Have you ever developed Guillian-Barre Syndrome within 6 weeks of receiving a flu vaccine? * Yes No Have you ever had a pneumonia shot? * Yes No Are you a smoker or have a chronic medical condition such as asthma, heart or lung disease? * Yes No If yes, please describe:Have you ever had a severe life threatening allergy to eggs or egg products? * Yes No Are you currently pregnant? * Yes No Do you have a history of asthma or wheezing? * Yes No Are you a child or adolescent receiving long-term aspirin therapy? * Yes No Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care? * Yes No Have you received any other vaccinations within the last 4 weeks? * Yes No Have you taken an antiviral medication for the flu within the last 48 hours? * Yes No Consent/AcknowledgeInfluenza Consent: I have read, or had explained to me, the Vaccine Information Statement about influenza vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. I request that the influenza vaccination be given to me (or the person named above for whom I am authorized to make this request). I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights. * Yes Pneumococcal Consent: I have read, or had explained to me, the Vaccine Information Statement about pneumococcal vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. I request that the pneumococcal vaccination be given to me (or the person named above for whom I am authorized to make this request). I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights. * Yes Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.
