Screening Questionnaire for Influenza Vaccine

  • Addendum to Inactivated Influenza Vaccine
    Vaccine Information Statement
    1. I agree that the person named below will get the vaccine checked below.
    2. I received or was offered a copy of the Vaccine Information Statement (VIS) for the vaccine listed above.
    3. I know the risks of the disease this vaccine prevents.
    4. I know the benefits and risk of the vaccine.
    5. I have had a chance to ask questions about the disease the vaccine prevents, the vaccine, and how the vaccine is given.
    6. I know that the person named below will have the vaccine put in his/her body to prevent the disease the vaccine prevents.
    7. I am an adult who can legally consent for the person names below to get the vaccine. I freely and voluntarily give my signed permission for this vaccine.

    Vaccine to be given: Inactivated Influenza Vaccine

  • Are you sick today?

  • Input blocked. Maximum character limit of 4000 characters reached.

  • Please contact Student Health Services at (903) 886-5853 to discuss.

Patient Information

section

  • Input blocked. Maximum character limit of 4000 characters reached.

  • Input blocked. Maximum character limit of 4000 characters reached.

  • Sex (at time of birth)

Visit Information

section

  • Have you ever had a serious reaction to the influenza vaccine in the past?
  • Have you ever had Guillain-Barre syndrome?

Certification and Agreement

section

  • I certify that this information is true and correct to the best of my knowledge.

    I hereby authorize Thomas C. Selvaggi, M.D.; Maxine Mendoza-Welch, PA-C; Emina Riebock, ANP-BC; or any providers associated with Student Health Services to release information acquired in the course of my immunization to any authorized medical provider involved in my care.

    I understand and agree that I am responsible for the fees for the services provided today.

  • STATEMENT: I authorize the release of any medical or other information necessary to process the claim. I also request payment of government benefits to the party who accepts assignment.

  • PRIVACY NOTIFICATION - With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See https://www.dshs.state.tx.us for more information on Privacy Notification (Reference Government Code Section 552.021, 552.023, 559.003, and 559.004)

  • Privacy Notice: I acknowledge that I have receive that I have received a copy of my immunization provider's HIPAA Privacy Notice.

  • By selecting "Submit" using any device, means or action, you consent to the requirements and expectations outlined in this document. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

{/_honeypot}