2009 H1N1 Influenza Vaccine Consent Form Section 1: Information about Person to Receive DATE OF BIRTH Vaccine (please print) NAME (Last) month_________ day________ year __________ PARENT/LEGAL GUARDIAN’S NAME (Last) Male / Female PHONE NUMBER: HISPANIC? YES NO SOCIAL SECURITY #: MARITAL STATUS
Section 2: Screening for Vaccine Eligibility If you/your child has already been vaccinated with 2009 H1N1 influenza vaccine, please tell us the number of doses and dates of vaccination. Dose 1 Date received: month ____day____year_______ Form (please circle): nasal spray shot Dose 2 Date received: month ____day____year_______ Form (please circle): nasal spray shot The following questions will help us to know if you/your child can get the 2009 H1N1 influenza vaccine. Mark YES or NO for each question. A. If you answer “NO” to all four of the following questions, you/your child can probably get the influenza vaccine. If you answer “YES” to one or more of the following four questions, your child may be able to get the 2009 H1N1 vaccine, but we may need to ask you more questions. 1. Does your child have a serious allergy to eggs? Yes_____ No_____
2. 2. Does your child have any other serious allergies including gentamicin, MSG,gelatin, arginine? Yes____No____Please list: ________________________ 3. 3. Has your child ever had a serious reaction to a previous dose of flu vaccine? Yes_____ No_____
4. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) within 6 weeks of receiving a flu vaccine?Yes_No_
B. There are two kinds of 2009 H1N1 influenza vaccine. Your answers to the following questions will help us know which of the two kinds of vaccine your child can get.
1 1. Has your child been vaccinated with any vaccine (not just flu) within the past 30 days? Yes_____ No_____ Shot?_____Nasal?_____
Vaccine: ___________________________________ Date given: month______day_______year___________ 2. Has your child taken any anti-viral medications in the last 48 hours? Yes_____ No_____ 3. Does your child have any of the following: asthma, diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves (seizures, hypotonia,Down’s syndrome), or blood? Yes_____ No_____ 4. Has your child younger than 5 years old experienced recurrent wheezing requiring albuterol, xopenex, or nebulizer therapy? Yes_____ No_____ 5. Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)? Yes_____ No_____
5. 6. Does your child have a weak immune system (for example, from HIV, cancer, or medications such as steroids or those used to treat cancer)?Yes___No__
7. Is your child pregnant? Yes_____ No_____
7. 8. Does your child have close contact with a person who needs care in a protected environment (for example, someone who has recently had a bone marrow
7. 9. Have you read the information from the American Academy of Pediatrics on Thimerosal in Vaccines and had your questions answered?Yes___ No____
Section 3: Consent CONSENT FOR VACCINATION: I have read or have had explained to me the information on the information form about H1N1 influenza vaccine. I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the risks and benefits of H1N1 influenza vaccine and request that the H1N1 influenza vaccine be given to me or the person named above for whom I am authorized to make this request. I have been provided access to the SouthPark Pediatrics Notice of Privacy Practices. I agree for Medicare, Medicaid and/or Insurance, if applicable, to be billed and I authorize the release of any medical information necessary to process this claim. I authorize payment of medical benefits to the SouthPark Pediatrics, PA. Signature of Client/Parent/Legal Guardian _________________________________________ Date: ________________________ Section 4: Vaccination Record FOR ADMINISTRATIVE USE ONLY Dose Number Date Dose Manufacturer/ Lot Name and Title of (1st or 2nd) Administered Vaccine Administrator STATE/MEDICAID / INSURANCE / MEDICARE Number ___________________________________________________________ Name as Listed _________________________________________________________ Effective / Valid Date(s) _____________________________________________ Vacc. Proc. Code 90663 G9142 (Medicare) Diagnosis V04.81 flu only Admin. Proc. Code 1 injectable - 90471 1 intranasal - 90473 Both inj. and intranasal – 90471 and 90474 G9141 (Medicare) ADD EP modifier when billing for Medicaid recipients from birth through 20 years of age. Sec. Initials______________________Sp3/clinical nurse binder/immunizations/11-09
r HEALTH AS A RIGHT fo A SYSTEM IN CRISIS In the World Health Organization’s Health Development Report (2000), the Philippines ranked 126th out of 191 countries in terms of over-all level of health. This is hardly surprising – in an era of lat astonishing complex medical and technological advancement, the country’s health profile is backward. Indeed, if the health of a nation is refl
• ABSTRACTS PRESENTED IN NATIONAL OR INTERNATIONAL MEETING AND WORKSHOPS 1- Mohsen I. Afouna, Ibrahim S. Khattab and Indra K. Reddy. Demeclocycline Liposomal Formulations: Preparation, Characterization and Assessment of their Intra-ocular Pressure Lowering Effects using rabbit model, The 9th International Pharmaceutical Sciences Meeting and Exposition, Dec. (2005). 2- Mohsen I. Afouna,