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