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: Zip/Postal Code:
	Telephone:	( ) -
	Email:
	Race:
	Ethnicity:
	Date of Birth:	/ /
	Sex:	Male Female

Funding for this website was made possible (in part) by the Department of Health and Human Services. The views expressed on this website do not necessarily reflect the official policies of the Department of Health and Human Services, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

	This voucher permits the individual named below to receive influenza vaccine.
	BRING THIS VOUCHER WITH YOU

	Dispense Assist
	Seasonal Influenza Vaccine Voucher

Vaccine:	Seasonal Influenza

Demographic Information
	First Name:	FirstName	Telephone:	Telephone
	Last Name:	LastName	DOB:	DOB
	Address:	Address	Age:	Age
	Address2:	Address2	Sex:	Gendor
	City, St Zip:	CSZ	Email:	Email
	Race:	Race	Ethnicity:	Ethnicity

Health History Information
	1.	Has this person had a serious reaction to the flu vaccine in the past?	No
	1a.	Person had cardiac arrest, collapsed or called 911 after getting vaccine?	No
	2.	Does this person have an allergy to eggs or egg products?	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?	No
	3.	Has this person ever had Guillain-Barre Syndrome (GBS)?	No
	3a.	Person had a history of GBS within six weeks after having a flu vaccination?	No
	4.	Is this person allergic to Thimerosal or mercury products?	No
	4a.	Person experienced respiratory distress or collapsed using Thimerosal products?	No

I, the undersigned, certify that all of the above information is correct to the best of my knowledge. I hereby authorize the recipient of this document to share this information with public health entities at the local, state and federal level for purposes of ensuring medication efficacy and safety. I have been offered a copy of Privacy Practices.

Client Signature:_____________________________________			Date Signed:________________

Clinician Use Only:

Vaccine Provided:	IM	Nasal	ID

Place Lot # Sticker Here		Location: (R) (L) (Deltoid) (VL)

Clinic Site:____________________________________


Vaccinator's Signature:______________________			Date:_____________

Fact sheet:

Vaccine Information Statements