Esta boleta permite al individuo nombrado abajo recibir este medicame.
TRAIGA ESTA BOLETA CON USTED
 
Dispense Assist
Seasonal Influenza Vaccine Voucher
 
Vaccine: Seasonal Influenza
 
Demographic Information
 First Name: Telephone:
 Last Name: DOB:
 Address: Age:
 Address2: Sex:
 City, St Zip: Email:
Health History Information
1. Has this person had a serious reaction to the flu vaccine in the past?
1a. Person had cardiac arrest, collapsed or called 911 after getting vaccine?
2. Does this person have an allergy to eggs or egg products?
2a. Person eat eggs or egg products?
3. Has this person ever had Guillain-Barre Syndrome (GBS)?
3a. Person had a history of GBS within six weeks after having a flu vaccination?
4. Is this person allergic to Thimerosal or mercury products?
4a. Person experienced respiratory distress or collapsed using Thimerosal products?
 
Yo, el suscrito, certifico que toda la información anterior es correcta de acuerdo a mi conocimiento. Por la presente autorizo al receptor de este documento a compartir esta información con los organismos de salud pública al nivel local, estatal y federal con el fin de garantizar la efectividad y seguridad del medicamento. Me han ofrecido una copia de las Prácticas de Privacidad.
Firma del Cliente:_____________________________________Fecha de Firma:________________
 
Clinician Use Only:
Vaccine Provided:  IM  Nasal  ID
 
 Place Lot # Sticker Here Location: (R) (L) (Deltoid) (VL)
 
Clinic Site:____________________________________
 
 
Vaccinator's Signature:______________________    Date:_____________
 
Fact sheet: Vaccine Information Statements