Patient Information

Patient Name:

Date:

Patient Address:

City:

State:

Zip:

DOB:

Gender:

Male

Female

Phone:

Allergies:

Alt Contact:

Relationship:

Weight (select one):

< 130 lbs

131-152 lbs

153-200 lbs

200-259 lbs

> 260 lbs

HCPC	Product	Dosage	Injection Site	Lot #	Exp.
	IIV:

Physician Information

Ordering Physician:

Physician Phone:

NPI:

Physician Fax:

Address:

City:

State:

Zip:

HB Pharmacy Vaccination Consent Form

I have read or had explained to me the Vaccine Information Statementforthe current influenza vaccine and understand the risk and benefit.

I understand that receipt of the vaccine does not completely protect me against the flu or other illnesses that resemble the flu. I further understand that if l have a condition (or am undergoing treatment which causes) or immune-suppression (the reduction in my body’s ability to fight infection and illness), the effectiveness of the vaccine in preventing the flu may be diminished.

I GIVE CONSENT to HB Pharmacy and licensed staff fo administer this vaccine to me. I hereby release HB Pharmacy and associated staff from any liability for giving me the influenza vaccination. I agree to defend and hold HB Pharmacy and associated staff harmless from any claim made by any person.

My signature on this form means that all of the information provided to HB Pharmacy is true to the best of my knowledge. If this consent form is not signed, dated and returned I will not be vaccinated.

Patient Signature:

Date:

Patient Name (Print):

I authorize HB Pharmacy to fax a Notification of Vaccination Letter to my Primary Care Provider

Physician Name:

Fax Number:

I do not authorize HB Pharmacy to fax a Notification of Vaccination letter to niy Primary Care Provider.

*If neither box is checked, a Notification of Vaccination Letter will be faxed to my Primary Care Provider, if identified.

VIS Given:

Version Date:

New Jersey Department of Health Vaccine Preventable Disease Program P.O. Box 369, Trenton, NJ 08625-0369 609-826-4860 (Fax 609-826-4866) www.njiis.nj.gov

NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS) CONSENT TO PARTICIPATE

- RETAIN A COPY OF THIS FORM IN THE MEDICAL RECORD -

REGISTRANT INFORMATION

Registrant Name (Print):

Date of Birth:

Country of Birth:

Name of Primary Health Care Provider:

PARENT/GUARDIAN INFORMATION (if NJIIS Registrant is a minor)

Name (Print):

Address:

City, State, Zip Code:

Relationship to Registrant:

I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history.

I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools, licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3.

I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department, or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number listed above.

There is no cost to participate in this program.

Yes, I would like to participate in this program.

No, I do not want to participate in this program.

Signature of Registrant (or Parent/Guardian, IF Registrant under 18 Years of Age):

Date:

Name of NJIIS Enrollment Site:

Registry ID Number:

Medical Record Number:

HB Pharmacy Authoritation Form - Medicare B

Statement to Permit Assignment of Benefits for Inactivated Injectable Influenza Vaccination

It is understood that HB Pharmacy has permission to ask for Medicare payments for medical care, including vaccinations.

It is understood that Medicare needs information about the patient and their medical condition to make a decision about payment. Permission is given for that information to go to Medicare and the companies that handle Medicare payment requests.

It is understood that the Centers for Medicare & Medicaid Services (CMS) is the government’s Medicare agency. It is understood that a photocopy of this release is as valid as the original document. Furthermore, it is understood that responsibility for paying any deductible or coinsurance amounts are that ofthe patient’s responsible party.

Therefore, it is asked that payment of authorized Medicare benefits be made on the patient’s behalf to HB Pharmacy for any services or items furnished to the patient by HB Pharmacy. It is authorized that any holder of medical or other information about the patient release such information to the Centers for Medicare & Medicaid Services (CMS) and its agents as needed to determine these benefits or benefits payable for related services.

Name:

Signature:

Date:

FORM COMPLETED BY DATE

DATE

FORM REVIEWED BY DATE

DATE

Notification of Vaccination Letter Template

Dear doctor or nurse at

We recently provided vaccination services to your patient. We want to make certain that you have information about the vaccines we administered so you can update your patient’s medical record. Please contact us if you have any questions about this information.

We provided the patient (or parent/guardian) with a written record of the vaccination(s) given.

We entered information about the vaccine(s) we administered in the regional or state immunization information system.

Patient’s name

Patient’s birthdate

For a child, Parent/guardian name

Parent/guardian birthdate

The vaccine(s) we administered on:

FLU VACCINATION VACCINATION INTAKE FORM

FLU VACCINATION INTAKE FORM

Patient Information

Physician Information

HB Pharmacy Vaccination Consent Form

New Jersey Department of Health Vaccine Preventable Disease Program P.O. Box 369, Trenton, NJ 08625-0369 609-826-4860 (Fax 609-826-4866) www.njiis.nj.gov

NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS) CONSENT TO PARTICIPATE

- RETAIN A COPY OF THIS FORM IN THE MEDICAL RECORD -

REGISTRANT INFORMATION

PARENT/GUARDIAN INFORMATION (if NJIIS Registrant is a minor)

I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history.

I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department, or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number listed above.

HB Pharmacy Authoritation Form - Medicare B

Statement to Permit Assignment of Benefits for Inactivated Injectable Influenza Vaccination

Screening Checklist for Contraindications to Vaccines for Adults

Screening Checklist for Contraindications to Vaccines for Children and Teens

Screening Checklist for Contraindications to Injectable Influenza Vaccination

Notification of Vaccination Letter Template

vaccines administered

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