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Influenza Vaccine Screening

Please complete the screening information below, then press the "Next" button at the bottom of the page for a printable voucher.

Dispense Assist does not retain your protected health information or other personal data that you provide. The only information retained by Dispense Assist is your IP address, which is not directly associated with any of your personal information. You are responsible for the security of any computer you use to input the information. At a minimum, you should clear your browser after you have printed your Voucher.

Personal Information

	First Name:	Last Name:
	Address:
	Address2/Other:
	City:	State/Territory: --Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming  Zip/Postal Code:
	Telephone:	( ) -
	Email:
	Race:	--Select One-- American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Unknown/Unreported
	Ethnicity:	--Select One-- Hispanic Non-Hispanic Unknown/Unreported
	Date of Birth:	/ /
	Sex:	Male Female

Medical Information
	1.	Has this person had a serious reaction to the flu vaccine in the past?	Yes No
	1a.	Has this person had cardiac arrest, collapsed or called 911 after receiving this vaccine in the past?	Yes No
	2.	Does this person have an allergy to eggs or egg products?	Yes No
	2a.	Has this person had a reaction to eggs involving symptoms other than hives, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention?�	Yes No
	3.	Has this person ever had Guillain-Barre Syndrome (GBS)?	Yes No
	3a.	Has this person had a history of GBS within six weeks after having a previous vaccination?	Yes No
	4.	Is this person allergic to Thimerosal or mercury products?	Yes No
	4a.	Has this person experienced respiratory distress or collapsed after using products containing Thimerosal?	Yes No
By checking the "Agree" box, I acknowledge that I have been offered a copy of the Vaccine Information Statements (Inactivated/Recombinant and Live, Attenuated) and I consent for the vaccine to be given to me or the person named above for whom I am authorized to sign. If there are any questions, please contact your local Health Department.
I Agree
	After completing the screening information, press the "Next" button for a printable voucher.

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