_________________________________                      ____/______/______
                  Name (please print)                                                 Date of Birth

________________________                ___West Haven___             ___06516___
                     Address                                               City                                      Zip

________________________                __F____M____          ___203 -_____-________
              Medicare Number                                  Sex                                    Phone

Yes_____   No_____ Do you want the Health Dept. to call you for a pneumonia shot ?

Yes_____   No_____ Are you allergic to eggs?

Yes_____   No_____ Have you ever had a serious reaction to a flu shot?

Yes_____   No_____ Are you sick with a fever?

Yes_____   No_____ Are you a pregnant?

Yes_____   No_____ Have you ever had Guillain-Barre Syndrome?
 

I have read, or had explained to me the information sheet about the influenza vaccine (flu shot).
I have had a chance to ask questions; which were answered to my satisfaction and I understand the benefits and risks of the vaccination as described.
I request that the influenza vaccine be given to me (or to the person above for whom I am authorized to make this request).
I authorize the release of any medical or other information necessary to process a Medicare claim

________________________________________                _______/________2002___
     Signature of recipient (or parent or guardian)                                            Date

________________________________________                _______/________2002___
     Signature of person reading form to client                                                  Date