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  • South Carolina Injectable Influenza Screening Questionnaire And Consent Form

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Medicare # Cash Insurance Carrier name Group # ID# South Carolina Injectable Influenza Screening Questionnaire and Consent Form Patient Information: (Patient to complete) *Patient Name: *Date of Birth:.

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Is the person to be vaccinated sick today? Does the person to be vaccinated have an allergy to an ingredient of the vaccine? Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? Has the person to be vaccinated ever had Guillain Barré syndrome?

Babies younger than six months old, people who have had a life-threatening reaction to a flu shot in the past, and people who are currently very sick with a high fever should not get a flu shot.

Other reasons included thinking they do not need a flu vaccine, fear of getting sick, fear of side effects from vaccination, being allergic to the vaccine, and thinking that flu vaccination is not good for you. Source: CDC, 2016.

I understand that I cannot get influenza from the influenza vaccine. my health and the health of those with whom I have contact, including all patients in this healthcare facility, coworkers, my family and my community. procedure masks in areas where patients or residents may be present during the influenza season.

Children younger than 6 months of age are too young to get a flu shot. People with severe, life-threatening allergies to any ingredient in a vaccine, including flu vaccine (other than egg proteins), should not get that vaccine. This might include gelatin, antibiotics, or other ingredients.

Current influenza vaccines have moderate efficacy, good safety, and acceptable tolerability; however, they have unsatisfactory efficacy in older adults, are dependent on egg supply for production, and are time-consuming to manufacture. This review outlines the unmet medical needs of current influenza vaccines.

Reasons for Refusing the Flu Vaccine “I do not need the vaccination” (17.3%) “I might experience side effects or get sick from the vaccine” (12.2%) “I don't think the vaccination is effective in preventing flu” (11.8%).

Medicare Part B provides preventive coverage only for certain vaccines. These include: Influenza: once per flu season (codes 90630, 90653, 90656, 90662, 90673-74, 90682, 90685-88, 90756, Q2035, Q2037, Q2039) Pneumococcal: (codes 90670, 90732, once per lifetime with high-risk booster after 5 years)

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232