Get NY DOH-4156 2014-2024

NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Immunization Influenza/Pneumococcal Immunization Consent Form Name Please Print Date of Birth Sex County of Residence Address City Phone For Persons Under 19 Years Old Mother s Maiden Name Medicare Claim Number Doctor s Name Health Insurance Provider Doctor s Address State ZIP NYSIIS Permission 19 Years Old Clinic/Office Site Where Vaccine Administered Policy Number No Yes Please complete the questions below for yourself or the person receiving the vaccine. Yes Are you currently sick with a fever Yes Have you ever had a life threatening allergy to any component or part of the flu or pneumonia vaccine If yes please describe Are you a smoker or have a chronic medical condition such as asthma heart or lung disease Have you ever had a severe life threatening allergy to eggs or egg products Are you currently pregnant Do you have a history of asthma or wheezing Are you a child or adolescent receiving long-term aspirin therapy Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care Have you received any other vaccinations within the last 4 weeks Have you taken an antiviral medication for the flu within the last 48 hours Influenza Consent Pneumococcal Consent I have read or had explained to me the Vaccine Information Statement about influenza vaccination* I have had a chance to ask questions which were answered to my satisfaction and I understand the benefits and risks of the vaccination as described* I request that the influenza vaccination be given to me or the person named above for whom I am authorized to make this request. I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights. about pneumococcal vaccination* I have had a chance to ask questions which were answered to my satisfaction and I understand the benefits and risks of the vaccination as described* I request that the pneumococcal vaccination be given to me or the person named above for whom I am authorized to make this request. I have received a copy of the Patient Bill of Rights. Signature of Recipient Parent or Guardian Date Area Below to Be Completed by Nurse Influenza Vaccine Pneumococcal Disease Vaccine Administration Date Dosage Left Arm Left Thigh Right Arm Right Thigh Nasal 0. 5 ml LAIV Manufacturer Lot Number VIS Date Nurse Signature Next Immunization Due DOH-4156 6/14 Next Year In 4 Weeks Other Immunizer White Provider Yellow Patient Pink None Needed. Yes Are you currently sick with a fever Yes Have you ever had a life threatening allergy to any component or part of the flu or pneumonia vaccine If yes please describe Are you a smoker or have a chronic medical condition such as asthma heart or lung disease Have you ever had a severe life threatening allergy to eggs or egg products Are you currently pregnant Do you have a history of asthma or wheezing Are you a child or adolescent receiving long-term aspirin therapy Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care Have you received any other vaccinations within the last 4 weeks Have you taken an antiviral medication for the flu within the last 48 hours Influenza Consent Pneumococcal Consent I have read or had explained to me the Vaccine Information Statement about influenza vaccination* I have had a chance to ask questions which were answered to my satisfaction and I understand the benefits and risks of the vaccination as described* I request that the influenza vaccination be given to me or the person named above for whom I am authorized to make this request. I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose. .