Consent For Services

Adult Consent

Step 1 of 5 - Event

Vaccination Event:

Clinic Location:(Required)

You must provide the correct location to be included in a Super Shot Clinic.

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FWCS Staff Location(Required)

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EACS Location(Required)

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ONE Location:(Required)

Please click to select a ONE Location

PHP Clinic Date(Required)

Patient’s Information:

Patient Name(Required)

First Last

Date of birth(Required)

Sex(Required)

Address(Required)

City(Required)

Zip(Required)

Email Address(Required)

Mobile Phone Number(Required)

Required Health Insurance Information:

Select One(Required)

Private Insurance (ex: CIGNA, PHP, BCBS, Signature Care)

Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise, CareSource)

Medicare or Medicare Replacement/Advantage Plan (Humana Gold, UnitedHealth Care, etc.)

No Insurance: I certify that named patient is not covered by any health insurance.

Insurance Company(Required)

Member ID(Required)

Group #(Required)

Social Security #(Required)

Medicare requires SSN for reimbursement purposes.

Policy Holder

Name

First Middle Last

Date of Birth(Required)

Employer(Required)

Relationship to Patient(Required)

Upload Insurance Card Image (Front)(Required)

Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.

Upload Insurance Card Image (Back)(Required)

Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.

Do you have an additional Medicare Card (Red, White, & Blue or Advantage Plan Card?(Required)

Yes

Medicare requires us to capture images of both Advantage Plan cards, and traditional Medicare cards cards, if available, for billing purposes. If you have any questions, please call Super Shot at (260)424-7468 and ask for Janet or email Janet.Paunwar@supershot.org. Thank you!

Upload Insurance Card Image (Front)(Required)

Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.

Upload Insurance Card Image (Back)(Required)

Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.

Demographic Information:

Number of People in Household(Required)

Annual Household Income(Required)

Race(Required)

Ethnicity(Required)

Language(Required)

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What gender do you identify with?(Required)

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Sexual Orientation(Required)

Do you have a disability?(Required)

Yes

Prefer not to answer

Answers are for the person getting the vaccine.

Do you have allergies to medications, food, a vaccine ingredient, or latex? (if yes, please note)(Required)

Yes

List allergies applicable to the previous question. Enter N/A if None(Required)

Have you ever had a serious reaction after receiving a vaccine?(Required)

Yes

Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19??(Required)

Yes

Are you pregnant?(Required)

Yes

Not Applicable

Do you have any of the following: (mark all that apply)(Required)

Chronic Heart Disease

Kidney Disease

Liver Disease

Complement Component Deficiency

Asplenia

Take a medication that lowers resistance to infection

History of Chickenpox

History of Gillian-Barre syndrome

Diabetes/Metabolic Disorder

Nervous System Disorder

Asthma/RAD

Blood Disease

CSF Leak

Cochlear Implant

Weakened Immune System, Cancer, Lupus, HIV/AIDS

None of the above

Consent

I would like Super Shot to provide the following vaccines:(Required)

Updated COVID-19

Influenza

High Dose Flu (65+)

Which Flu Vaccine would you like to receive?(Required)

2024-2025 Flu

Updated Covid

Pneumococcal—recommended for age 65+

RSV-recommended for age 75+ and age 60-75 with comorbidities

Shingles-recommended for age 50+

I consent to receiving Flu Vaccination services from Super Shot.(Required)

Yes

Communication

It's ok to call me

It's ok to TXT me

All information I have provided on the consent for vaccination is true and correct. I am aware of the HIPAA Notice of Privacy Policy available at supershot.org. I am aware and understand the CDC Vaccine Information Statements for the vaccines the patient will receive today available at https://www.cdc.gov/vaccines/hcp/vis/index.html. I give permission to Super Shot to all vaccinations indicated and selected above, to communicate with other healthcare providers, as needed, and for data entry, billing, and storage according to Indiana Department of Health policies. By signing below I agree to the payment option for today’s services that I have selected. I understand that if I have asked for a claim to be filed to my insurance company, I am responsible for charges not covered by my insurance plan and agree to pay them in full.

Consent for Vaccine Services(Required)

I attest

All information I have provided on the consent for vaccination is true and correct. I am aware of the HIPAA Notice of Privacy Policy available at supershot.org. I am aware and understand the CDC Vaccine Information Statements for the vaccines the patient will receive today available at https://www.cdc.gov/vaccines/hcp/vis/index.html. I give permission to Super Shot to provide all vaccinations indicated and selected above, to communicate with other healthcare providers, as needed, and for data entry, billing, and storage according to Indiana Department of Health policies. I understand that through a partnership with Fort Wayne Community Schools, the vaccines will be delivered, stored, and administered by FWCS nursing staff. By signing below I agree to the terms stated above and the payment option for today’s services that I have selected. I understand that if I have asked for a claim to be filed to my insurance company, I am responsible for charges not covered by my insurance plan and agree to pay them in full.

Date(Required)

Signature(Required)

Adult Consent

Vaccination Event:

Patient’s Information:

Required Health Insurance Information:

Demographic Information:

Consent

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