R “yes” to any of these questions, or don’t know the answer, please don’t sign this form without talking to your doctor or nurse. Please read the Vaccine Information Statements (VIS) we gave you for the vaccine you are getting today. Influenza Vaccine Card / Sticker Yes No yy this person had a serious (life-threatening) allergic reaction to any previous dose of the vaccine(s) Has or vaccine components? .
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How to fill out the WA GroupHealth DA-2776 online
Filling out the WA GroupHealth DA-2776 form is an essential step in consenting to receive the or Injectable Adult Flu Vaccine. This guide will walk you through the necessary steps to complete the form accurately online, ensuring that you understand each component and what information is required.
Follow the steps to successfully complete your vaccination consent form.
- Press the ‘Get Form’ button to access the WA GroupHealth DA-2776 form. This will allow you to open the document in an editable format.
- Begin by filling out the personal information section, which includes your name, member I.D. number, and date of birth.
- Carefully read the questions regarding your medical history related to the vaccine. For each question, mark ‘Yes’ or ‘No’ as it applies to you.
- If you answer ‘Yes’ to any question, or if you are unsure, it is important to discuss your answers with your healthcare provider before signing.
- Once all questions have been answered and discussed with a healthcare professional if necessary, read the vaccine information statements provided.
- Provide your signature in the designated area to authorize consent for the vaccine administration.
- Complete the staff use section as required, which pertains to the vaccine type administered and provides additional details.
- Finally, review all information for accuracy. You can then save changes, download, print, or share the completed form as needed.
Complete your WA GroupHealth DA-2776 form online for a smooth vaccination process.
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You can contact Washington State Health Plan Finder by visiting their official website for contact details, or by calling their helpline directly. They are available to assist you with any inquiries, including those about WA GroupHealth DA-2776. Don’t hesitate to reach out for support regarding your health plan.
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