Exit Flu Immunization Registration Form Question Title * 1. Name: Question Title * 2. What is the clients date of birth? Question Title * 3. What is clients gender? Female Male Question Title * 4. Phone: Question Title * 5. Address: Question Title * 6. Health Insurance Information Company Name ID number Name of policy holder Policy holder DOB NO INSURANCE Question Title * 7. Which race/ethnicity best describes client? (Please choose only one.) American Indian or Alaskan Native Asian / Pacific Islander Black or African American Hispanic White / Caucasian Multiple ethnicity / Other (please specify) Question Title * 8. Check all that apply to the client. Had a serious reaction to a flu shot in the past Has a chronic condition affecting lungs, kidneys, liver, spleen, neurological or metabolic system? Has had Guillain-Barre syndrome Has a cochlear implant or a cerebrospinal fluid leak or is pregnant. Works closely with immunocompromised people. Is sick today and has a fever. None of the above Question Title * 9. If you selected any of the above conditions the regular shot is required. Would you like the client to receive Nasal Mist or the regular Flu Shot. Regular Flu Shot Nasal Mist Question Title * 10. What school flu clinic will client be at? Kulm School Edgeley School Litchville-Marion School LaMoure School Question Title * 11. I acknowledge that I have read or understand and can obtain the information about the flu vaccine my child will receive at (https://www.cdc.gov/vaccines/hcp/vis/current-vis.html). I understand that I can call 701-883-5356 or email jduffy@nd.gov any questions I may have. I authorize the release of information necessary to process the immunization through my insurance and I agree to pay LaMoure County charges not covered by insurance and I authorize my insurer to make direct payment to LaMoure County Public Health for the clients care/immunization. Please type your signature. Done
