VOUCHERS FOR:
 
 
 
 
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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:        
  Address: 
  Address2/Other: 
City:   State/Territory:  Zip/Postal Code:
  Telephone:  ( ) -
Email: 
  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
  2. Does this person have an allergy to eggs or egg products?
Yes No
  3. Has this person ever had Guillain-Barre Syndrome (GBS)?
Yes No
  4. Is this person allergic to Thimerosal or mercury products?
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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