Immunization Form | Ridgewood Primary Care

Preferred Location *

Last Name^*

First Name^*

Date of Birth^*

Sex^*
Male Female

Phone^*

County of Residence

Address

City

State

Zip

For Persons Under 19 Years Old, Mother’s Maiden Name

Medicare Claim Number

Doctor’s Name

Health Insurance Provider

Doctor’s Address

Policy Number

NYSIIS Permission ≥ 19 Years Old
Yes No

Clinic/Office Site Where Vaccine Administered

Influenza 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. Irequest 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.

Signature of Recipient (Parent or Guardian)

Date

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 otherinformation 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.

Signature of Recipient (Parent or Guardian)

Date

YES NO	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? If yes, please describe:
YES NO	Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving 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? If yes, please describe:
YES NO	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?

Influenza/ Pneumococcal Immunization Consent Form

All Forms

Influenza Consent

Pneumococcal Consent