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VACCINE CONSENT FORM
STUDENT INFORMATION
IF YOUR SCHOOL'S CLINIC IS WITHIN THE NEXT 3 SCHOOL DAYS, YOUR
REGISTRATION MAY NOT BE REVIEWED IN TIME. YOUR TEEN WILL BE SCHEDULED
FOR THE NEXT CLINIC.
School
*
Year of Graduation
*
Email Address
Student Last Name
*
Student First Name
*
Date of Birth
*
Street Address
*
City
*
State
*
Zip Code
*
Sex (assigned at birth)
*
Male
Female
Gender Identity (optional):
Cisgender (same as sex assigned at birth)
Gender non-conforming/non-binary
Trans
Something else
Prefer not to answer
Race:
*
American Indian or Alaska Native
Asian
Black
Native Hawaiian and Pacific Islander
White
Some other race
Prefer not to answer
Ethnicity:
*
Hispanic or Latino
Not Hispanic or Latino
Unknown
Prefer not to answer
Parent/Guardian Name
Daytime Phone Number
*
Insurance Company
*
ACE American Ins. Co
AETNA
Blue Cross Blue Shield of RI
Cigna Carelink
Harvard Pilgrim
Medicare
Neighborhood Health Plan of RI
Tricare
Tufts
United Healthcare
Other
No Insurance
Member ID
*
Group # (if applicable)
SCREENING FOR ROUTINE VACCINE ELIGIBILITY
1. Does the patient have allergies to medications, food, or any vaccine?
*
Yes
No
If yes, list:
If yes, list:
2. Has the patient ever had a serious reaction to a vaccine?
*
Yes
No
If yes, list:
If yes, list:
3. In the past three months, has the patient taken medications for the treatment of rheumatoid arthritis, Crohn's disease, or Psoriasis?
*
Yes
No
4. Has the patient, a sibling, or a parent ever had a seizure or brain problem?
*
Yes
No
5. Does the patient have cancer, leukemia, HIV/AIDS, or any other immune system condition?
*
Yes
No
6. Has the patient received a blood transfusion, blood products, or immune (gamma) globulin in the past year?
*
Yes
No
7. Has the patient received any vaccinations in the past four weeks or taken an antiviral drug?
*
Yes
No
If yes, list:
If yes, list:
8. Does the patient have a long-term health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak?
*
Yes
No
9. Is the patient on long-term aspirin therapy?
*
Yes
No
10. Does the patient have a parent, brother, or sister with an immune system problem?
*
Yes
No
Would the patient like to receive the flu vaccine?
*
Yes
No
Would the patient like to receive the COVID vaccine?
*
Yes
No