Patients Form Acceptance/Declination of the Influenza VaccineFirst Name*Last Name*Phone*Email* The CDC recommends that everyone over the age of 6 months get an annual influenza vaccination. I understand that I have been offered the vaccine, and if I decline to receive the vaccine, I am fully informed of the risks and benefits of the vaccination. I accept receipt of the influenza vaccination I refuse to take the annual flu shot Patient Insurance Information for Influenza VaccinationPatient Name*Patient Date of Birth* Date Format: MM slash DD slash YYYY Primary Insurance NameMember ID/Cardholder ID/Medicare NumberBinPCNGroupThe following questions help us determine which vaccines you may be given today. If you answer “yes”, it does not necessarily mean you should not be vaccinated. If a question is not clear, please ask your pharmacist to explain it.1. Are you sick today?*YesNoDon’t Know2. Do you have allergies to medications, food (e.g. eggs), latex, or a vaccine component (e.g. gelatin, neomycin, polymyxin, yeast, thimerosal, etc.)?*YesNoDon’t Know3. Have you ever had a serious reaction (including fainting) after receiving a vaccination?*YesNoDon’t Know4. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?*YesNoDon’t Know5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, or Crohn’s Disease?*YesNoDon’t Know6. In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*YesNoDon’t Know7. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?*YesNoDon’t Know8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*YesNoDon’t Know9. For women: are you pregnant or is there a chance you could become pregnant during the next month?*YesNoDon’t Know10. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a physician's office or hospital?*YesNoDon’t Know11. Have you received any vaccinations in the past 4 weeks?*YesNoDon’t Know12. For the Td or Tdap vaccine: Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?*YesNoDon’t KnowIf you are 65 years or older: Have you had the following vaccines?Pneumococcal VaccineYesNoDon’t KnowZoster/Shingles VaccineYesNoDon’t KnowI authorize the pharmacist to send copies of my vaccine documents to my primary care provider.YesNoI acknowledge that the information here is true to the best of my knowledge, that I have read the Vaccination Information Sheet (VIS) provided, and that my vaccination record may be shared with my healthcare provider and federal or state agencies for registry reporting.