School Name: ________________________ Grade: _______ TAX ID: 611630276
Group NPI: 1225327984
4527 E. 82nd Street Indianapolis, IN 46250 317-528-6374 NPI: 1770595357
Name: ______________________________________________________________ Birthdate: __________________ Age: ___________ Race: _______________ Gender: M or F
Address: _____________________________________________________________________________ City: __________________________ State: _________ Zip: ____________
Phone Number: ____________________________________ Parents Name: ________________________________________ Mothers Maiden Name: _________________________
Primary Insurance Company: ______________________________________ Member ID: __________________________________________ Group ID:
_________________________
Insurance Company phone Number: ___________________________ Policy Holder: _____________________________ Birthdate: __________ Employer: ______________________
Secondary Insurance Company: ____________________________________ Member ID: __________________________________________ Group ID: ________________________
Insurance Company phone Number: ___________________________ Policy Holder: _______________________________ Birthdate: __________ Employer: ____________________
Please circle any optional Vaccinations you would like your child to receive:
HPV, Flu Shot, Bexsero (Meningococcal Group B)
YOUR CHILD NEEDS THE FOLLOWING VACCINATIONS TO STAY IN SCHOOL:
SCHOOL STAFF, PLEASE CIRCLE NEEDED VACCINE:
Dtap, Hep A, Hep B, MMR, Varicella, Meningitis MCV4, Tdap
IMPORTANT NOTICE
If you do not have insurance, or your insurance company does not cover vaccinations there is a $10 fee PER vaccination received.
If you cannot afford any or all the vaccinations please call our office to see if you qualify for assistance. 317-528-6374
Medical History: The following will help us determine your eligibility for requested immunizations. Please answer to the best of your ability.
1. Are you Pregnant or planning a pregnancy in the next 4 weeks? YES NO
2. Are you currently ill with a fever, vomiting or diarrhea? YES NO
3. Have you received blood/plasma/immune globulin or had a vaccine in the last 4 weeks? YES NO
4. Have you ever fainted, became dizzy or had a serious reaction after an immunization? YES NO
5. Have you ever had a seizure disorder for which you require medication, a brain YES NO
Disorder, Guillain-Barre Syndrome or any other nervous system disorder?
6. Are you allergic to any medications, foods or vaccines and their components? YES NO
(such as eggs, bovine protein,toxoids,sorbitol,neomycin,phenol,yeast,thimerosal,latex,protamine sulfate,
formaldehyde, hypersensitivity to gelatin)
ACKNOWLEDGEMENT/ RELEASE OF LIABILITY AND CONSENT TO RECEIVE IMMUNIZATION(S):
WRITTEN MD APPROVAL IS REQUIRED FOR CHILDREN UNDER THE AGE OF 8 YEARS FOR POLIO, RABIES AND MMR. YELLOW FEVER REQUIRES WRITTEN MD APPROVAL FOR
PERSONS WITH MULTIPLE SCLEROSIS, CHILDREN UNDER 9 YEARS OR ADULTS OVER 59 YEARS. HEPATITIS A, B OR COMBO VACCINES ALSO REQUIRE MD APPROVAL FOR
PERSONS WITH MS.
I HAVE READ OR HAVE BEEN OFFERED A COPY OF THE CURRENT VACCINE INFORMATION SHEET PRIOR TO MY VACCINATION. I HAVE HAD A CHANCE TO ASK QUESTIONS AND I
UNDERSTAND ALL THE RISKS AND BENEFITS INVOLOVED.
I AGREE TO STAY IN THE AREA FOR 15 MINUTES AFTER RECEIVING MY VACCINATION TO ENSURE THAT NO IMMEDIATE REACTIONS OCCUR. I UNDERSTAND THAT IF I
EXPERIENCE ANY SIDE EFFECTS IT WILL BE MY RESPONSIBILITY TO GOLLOW UP WITH MY PHYSICAN AT MY EXPENSE. LOCAL REACTIONS MAY INCLUDE BURNING, SWELLING,
WHEAL, TENDERNESS OR BLISTERING AT SITE. GENERAL REACTIONS MAY INCLUDE FEVER, FATIGUE, DIARRHEA, NAUSEA, VOMITING, HEADACHE, ARTHRITIS, MALAISE AND
MYALIA. SEVERE REACTIONS INCLUDE ANAPHYLAXIS, ENCEPHALITIS, GUILLAIN-BARRE AND FEBRILE CONVULSIONS.
I UNDERSTAND THE VACCINE IS BEING PROVIDED BY FRANCISCAN WORKINGWELL. I EXPRESSLY RELEASE FROM ANY LIABILITY THE ABOVE NAMED ORGANIZATION AND
INDIVIDUAL GIVING THE VACCINE(S). I, FOR MYSELF, MY HEIRS, EXECUTORS AND ASSIGNS HEREBY AGREE TO RELEASE THE SITE PROVIDER AND ITS EMPLOYEES FROM ANY
AND ALL CLAIMS ARISING OUT OF, IN CONNECTION WITH OR IN ANY WAY RELATED TO MY RECEIPT OF THIS VACCINE(S) IN THEIR FACILITIES.
I HAVE READ THIS CONSENT AND I AUTHORIZE FRANCISCAN WORKINWELL TO GIVE THE ABOVED NAMED VACCINE TO ME OR THE PERSON NAMED FOR WHICH I AM AUTHORIZED
TO SIGN.
I ACKNOWLEDGE THAT SOME VACCINES REQUIRE MULTIPLE DOSES AND/OR UP TO 2 WEEKS TO RECEIVE FULL PROTECTION.
ASSIGNMENT OF BENEFITS: I HEREBY AUTHORIZE ANY INSURANCE WITH WHOM I HAVE A POLICY TO PAY DIRECTLY TO THE HEALTHCARE PROVIDERS ANY BENEFITS
OTHERWISE PAYABLE TO ME. I HEREBY TRANSFER AND ASSIGN THE BENEFITS OF ANY POLICIES OF INSURANCE TO THOSE HEALTHCARE PROVIDERS WHO HAVE RENDERED
SERVICES TO ME AND WHO ACCEPT SUCH ASSIGNMENT. I UNDERSTAND THAT I WLL BE FULLY RESPONSIBLE FOR PAYMENT OF ANY AND ALL CHARGES NOT PAID BY MEDICAL
INSURANCE. IF ANY AMOUNTS FOR WHICH I AM RESPONSIBLE BECOME DELINQUENT, I AGREE TO BE RESPONSIBLE FOR ANY EXPENSES PAID BY FRANCISCAN ALLIANCE AND
HEALTHCARE PROVIDERS TO COLLECT THE AMOUNTS, INCLUDING REASONABLE ATTORNEY FEES.
I UNDERSTAND THAT THERE MAY BE A DELAY, WHICH COULD BE MORE THAN 6 MONTHS, BETWEEN THE TIME I SIGN THIS CONSENT AND WHEN THE IMMUNIZATIONS ARE GIVEN
TO MY CHILD. AS SUCH, I AGREE THAT IT IS MY SOLE RESPONSIBILITY TO MAINTAIN A COPY OF THIS CONSENT, TO NOTIFY THE SCHOOL OR FRANCSICAN IMMUNIZATIONS, AND
TO PROVIDE AN UPDATED CONSENT IF MY ANSWERS CHANGE, OR MY CHILDS HEALTH CHANGES.
PLEASE NOTE THAT IF YOU HAVE NOT ANSWERED OR FILLED OUT ALL INFORMATION WE WILL NOT VACINATE YOUR CHILD.
X_______________________________________________________________________ _____________
Patient Signature (parent or guardian if patient is under 18), Offered/Read HIPAA Privacy Practices Date
Additional lines are for second and third dose consent.
X_______________________________________________________________________ _____________
Patient Signature (parent or guardian if patient is under 18), Offered/Read HIPAA Privacy Practices
X_______________________________________________________________________ _____________
Patient Signature (parent or guardian if patient is under 18), Offered/Read HIPAA Privacy Practices
**********************Office USE ONLY************************
*staff always use a red check mark to identify vaccine was recorded in chirp on far right side of administered vaccine.
CPT VACCINE/ VIS DATE/ROUTE & SITE LOT# & EXP. CLINICIAN SIGNATURE & DATE DATE PAID
CODE DOSAGE SCHEDULE BILLED
90633- P Left or Right
PRI.77
HEPATITIS A (1yr&up) 1
VFC.8 VIS Date: 7/20/16
90632-A Dosage - IM .5 or 1CC Left or Right
PRI.103
2
Schedule- now and 6-12 months
90744-P Left or Right
PRI.94
HEPATITIS B (birth&up) 1
VIS Date: 7/20/16
Left or Right 2
Dosage – IM .5 or 1CC
VFC.8
Schedule- now, 1 month, 6 month Left or Right 3
90746-A
PRI.120
HPV9 Gardasil9 (9yrs-26yrs) Left or Right 1
VIS Date: 12/2/16
90651 Dosage – IM .5 or 1CC Left or Right 2
PRI.224 Schedule’s –
VFC.8 (9yrs-14yrs ) -2 dose–now, 6months Left or Right 3
(15yrs&up) - 3 dose-now, 2 months,&
6months
90620 Meningococcal B (16yrs&up) Left or Right 1
PRI.220 VIS Date: 8/9/16
VFC.8 Dosage – IM .5CC Left or Right 2
Schedule- 1 month apart
Meningococcal (MCV4) (11yrs&up) Left or Right 1
90734 VIS Date: 3/31/16
Schedule- Dosage – IM .5CC
PRI.284 1st dose at age 11 or 12 (6th grade) Left or Right 2
VFC.8 2nd dose at age 16 or (senior year)
90715 Tdap(10yrs&up) Left or Right 1
PRI.138 VIS Date: 2/24/15 Dosage – IM .5CC
VFC.8 (Tetanus, Diphtheria, Pertussis)
MMR-V (LIVE) (ProQuad) (1yr-12yrs) Left or Right 1
VIS Date: 2/12/18
90710
Schedule- Dosage –SUBQ .5CC
PRI.326 Left or Right 2
1st dose at 1yr, 2nd dose at 4-6yrs old
VFC.8
**DO NOT GIVE AFTER AGE 13
MMR (LIVE) (1yr&up) Left or Right 1
VIS Date: 2/12/18 Dosage –SUBQ .5CC
90707
PRI.141 Schedule- 1st dose at 1yr, 2nd dose at 4-6yrs old Left or Right
VFC.8 (may be given earlier, if at least 28 days after
2
the 1st dose)
VARICELLA (LIVE) (1yr&up) Left or Right 1
VIS Date: 2/12/18 Dosage –SUBQ .5CC
90716
PRI.237 Schedule- 1st dose at 1yr, 2nd dose at 4-6yrs old Left or Right
(may be given earlier, if at least 28 days after
2
VFC.8
the 1st dose)
