Parent Screening Questionnaire forInactivated Injectable In�uenza Vaccination

Parent Name: ___________________________________ Today’s Date: _____________Date of Birth: _______/______/______

MM DD YYYY

� � � �� � � � � �� � � � � � � � �� � �� � � � �� � �� � � � � � � �� � �� � � � � � � � �� � � � �� � � � � � � � � � : The following questions will help us determine if there is any reason we should not give you the inactivated injectable in�uenza

vaccination today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked.

If a question is not clear, please ask your healthcare provider to explain it.

1. Are you sick today?2. Do you have an allergy to eggs or to a component of the vaccine?3. Have you ever had a serious reaction to the In�uenza Vaccine (Flu Shot)?4. Have you ever had Guillain-Barré syndrome? *Guillain-Barré syndrome: a rare neurological disorder in which the body's immune system mistakenly attacks part of its peripheral nervous system.

YES NO NOT SUREYES NO NOT SURE

YES NO NOT SURE

YES NO NOT SURE

FORM COMPLETED BY: ____________________________________________Signature

Date Vaccine Administered

______________________Vaccine Manufacturer

______________________Vaccine Lot Number ______________________Site of Injection

______________________Signtature and Title

______________________

Please Circle Your Answer

1500 West 38th Street, Suite 20Austin, Texas 78731

(512) 458-5323 Fax: (512) 458-2030Samuel Mirrop, MD • Lance Hargrave, MD • Ashley Gonzalez, MD

Brandi Loomis, MD • Jessica Mowry, MD • Katie Sanford, MDEmily Woodard, RN, CPNP • Amber Mercer, RN, CPNP

Jenny Pyle, RN, CPNP • Erin Moore, RN, CPNP

Not Paid

Paid

Initials: ___________

Not Paid

Cash

Check#____________

Card: _____________

Amount: __________

Initials: ___________

Vender + Last 4 Digits

Flu Shot Waiver

The purpose of this waiver is to inform you that Pediatric Associates is providing you with a �ushot today as a courtesy. We will not be �ling your insurance, nor will we refund any write o� your insurance plan may pass on to you.

I understand these terms and agree to pay $42 for the �u shot and the administration of this vaccine at the time of service.

____________________________________Print Name

____________________________________Signature

____________________________________Date

____________________________________Account#

Dx Code: Z23Procedure Code: PFLU