Knoxcounty.org

ATTENTION PARENTS:
SCAN THE QR CODE AT THE RIGHT OR GO TO https://www.zippslip.com/knox TO COMPLETE THE CONSENT PROCESS ON-LINE
Or, if you don’t want to complete the consent process on-line, please complete this form and return it to your child’s homeroom teacher. Please do not do both.
KCHD STUDENT INFLUENZA CONSENT FORM
Official Vaccine Source: VFC KCHD
Use Vaccine Naïve: Yes No
Immunization Nursing Record - SLVC 2013
Only Vaccine Type: IIV: 6-35m 36m+ LAIV
PLEASE PRINT
Grade: ________ Age: _________ DOB: _____/_____/_______ SS# ___________________________ School: _______________________________ Home Room Teacher: (First Name) __________ (Last Name)____________ Child’s Name - First: __________________________ MI: _____ Last: _________________________________________ Address: ________________________________________ City:_________________________ Zip Code:_____________ Home Phone: ( ) ______-________ Cell Phone: ( ) ______-________ Emergency Number: ( ) ______-________ Email:___________________________________________________ Child’s Pediatrician:_________________________ Mother’s Name:___________________________________ Father’s Name:_____________________________________ Guardian, if under 18 - Name: _______________________________________ Relationship:_________________________ Gender: Male Female Primary Language: ______________________ Hispanic: Yes No Race: White Black Asian American Indian Alaskan Native Other:___________________________ Insurance: Private Insurance TennCare No Insurance Private Insurance (but does not cover flu) Primary Insurance Name: ______________________________ Member ID: _____________ Group ID: _______________ Insurance Address: ______________________________________________________________________________ Subscriber Name: __________________________ Subscriber DOB_______________________________________ Secondary Insurance Name: ___________________________ Member ID: _____________ Group ID: ________________ Insurance Address: ______________________________________________________________________________ Subscriber Name: __________________________ Subscriber DOB_______________________________________ Please answer NO or YES to the questions below.
Please Circle
The questions are answered for the person receiving the vaccination.
1. Has your child ever received an influenza vaccination? If unsure, mark No. 2. Has your child received a vaccine within the past 30 days? Name of Vaccine(s): Date: 3. Has your child ever had a severe (life threatening) allergic reaction to the flu vaccine such as wheezing or hives? 4. Does your child have any of the following: - chronic heart diseases - diabetes or other metabolic diseases/disorders - blood diseases - asthma/reactive airway disease/wheezing - an inhaler that is used regularly - kidney diseases 5. Is your child allergic to vaccine components such as eggs, gentamicin, arginine, gelatin, MSG? 7. Has your child ever had Guillain-Barre´ syndrome? 8. Is your child on long-term aspirin therapy or taking Tamiflu®, Relenza®, amantadine, or rimantadine? 9. Does your child have a disease such as cancer, lupus, HIV/AIDS, or take a medication that lowers the body’s resistance to 10. Does your child have close contact with anyone who has had a bone marrow transplant in the last 6 months? Consent for Administration of Influenza Vaccine for the above named recipient: I am aware that the receiver of this vaccine is currently not pregnant nor will
become pregnant within four weeks of receiving this vaccine. I have read information about the vaccine and special precautions on the Vaccine Information Sheet. I have had an
opportunity to ask questions regarding the vaccine and understand the risks and benefits. I request and voluntarily consent that the vaccine be given to the person above of whom I
am parent or legal guardian and acknowledge that no guarantees have been made concerning the vaccine’s success. I hereby release Knox County Government, their affiliates,
employees, directors, and officers from any and all liability arising from any accident, act of omission or commission, which arises during vaccination. This consent gives Knox
County Health Department permission to file rendered services to your insurance carrier. Consent form is valid 6 months from date of initial signature.
_________________________________________________ _______________________ OFFICIAL USE ONLY
PHASE ONE
___VFC ___ KCHD Mfr/Lot: _______________ NDC#: _________________ Expiration: _________ Amount: ______ Date Given: __________ VIS Date:________ Route: _____ Site: ______ Signature: _________________________ Provider ID: __________ PHASE TWO
___VFC ___ KCHD Mfr/Lot: _______________ NDC#: _________________ Expiration: _________ Amount: ______ Date Given: __________ VIS Date:________ Route: _____ Site: ______ Signature: _________________________ Provider ID: __________

Source: http://www.knoxcounty.org/health/pdfs/flu_consent.pdf