Consent For Services Adult Consent Step 1 of 5 - Event 0% Vaccination Event:Clinic Location:(Required)Please Select a Location2/21 FWCS Pneumococcal/TdapYou must provide the correct location to be included in a Super Shot Clinic. FWCS Staff Location(Required)Please Select LocationAbbettAdamsAnthisArlingtonBlackhawkBloomingdaleBrentwoodBuncheCatalpaCroningerFairfieldForest ParkFranke ParkGlenwood ParkGrilleHaleyHarrisHarrison HillHollandIndian VillageIrwinJeffersonKekiongaLakesideLaneLincolnLindleyMaplewoodMemorial ParkMiamiNatatoriumCAS NebraskaNew Tech AcademyNorth SideNorthcrestNorthropNorthwoodPortagePriceScottShambaughShawneeSniderSouth SideSouth WayneSt JoeStudyTowles IntermediateWashingtonWashington CenterWayneWaynedaleWeisser ParkWhitney YoungTransportationNutritionFACEThis field is hidden when viewing the formEACS Location(Required)Please Select a Location:Cedarville ElementaryEast Allen UniversityEast Allen Alternative SchoolEast Allen Career CenterHeritage ElementaryHeritage Jr/Sr High SchoolLeo ElementaryLeo Jr/Sr High SchoolNew Haven Intermediate SchoolNew Haven Junior High SchoolNew Haven Primary SchoolPaul Harding Jr High SchoolPrince Chapman AcademySouthwick Elementary SchoolWoodlan ElementaryWoodlan Jr/Sr High SchoolThis field is hidden when viewing the formONE Location:(Required)Please click to select a ONE LocationPlease Select LocationN. Clinton 9:00amParkview Circle 1:00pmGlencarin Blvd. 3:00pmThis field is hidden when viewing the formPHP Clinic Date(Required)Please Select a Location:10/16/2024 6:30am-9:30am10/25/2024 7am-9amPatient’s Information:Patient Name(Required) First Last Date of birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required)Select OneMaleFemaleAddress(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 HolderName First Middle Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer(Required)Relationship to Patient(Required)Select OneSelfSpouseChildOtherGrandparentGrandchildNephew or NieceFoster ChildWardStepson or StepdaughterEmployeeHandicapped DependentSponsored DependentDependent of a Minor DependentSignificant OtherMotherFatherEmancipated MinorLife PartnerUpload 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 No 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)Please Select One123456789101112131415More than 15Annual Household Income(Required)Please Select Income RangeBelow $11,800$11,881-$24,300$24,301-$36,450$36,451-$48,600$48,601-$60,750$60,751-$72,901Over $72,901Race(Required)Select OneWhiteAfrican AmericanAsianHispanicAmerican IndianNatl. Hawaiian, Pac IslAlaskan NativeOtherEthnicity(Required)Select OneHispanic/LatinoNot Hispanic/LatinoDecline to AnswerLanguage(Required)Select OneEnglishSpanishBurmeseOtherPrefer not to answerThis field is hidden when viewing the formWhat gender do you identify with?(Required)Select OneMaleFemaleNon-BinaryOtherPrefer not to answerThis field is hidden when viewing the formSexual Orientation(Required)Select OneStraight/HeterosexualLesbian or GayBisexualOtherPrefer not to answerDo you have a disability?(Required) Yes No 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 No List allergies applicable to the previous question. Enter N/A if None(Required) Add RemoveHave you ever had a serious reaction after receiving a vaccine?(Required) Yes No This field is hidden when viewing the formHave 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 No Are you pregnant?(Required) Yes No 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 ConsentThis field is hidden when viewing the formI would like Super Shot to provide the following vaccines:(Required) Updated COVID-19 Influenza High Dose Flu (65+) This field is hidden when viewing the formWhich 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+ Select AllThis field is hidden when viewing the formI consent to receiving Flu Vaccination services from Super Shot.(Required) Yes No I would like Super Shot to provide the pneumococcal vaccine. I have read the following recommendations and should receive my Pneumococcal vaccine at this time:Pneumococcal vaccine is indicated for adults 50+ who have not previously completed their pneumococcal series or ages 19-49 with the following conditions. Please speak to your PCP or call Super Shot at (260)4247468 if you have any questions. • Diabetes mellitus • Alcoholism or cigarette smoking • Chronic heart disease o Includes congestive heart failure and cardiomyopathies o Excludes hypertension • Chronic lung disease o Includes chronic obstructive pulmonary disease, emphysema, and asthma • Chronic renal failure or nephrotic syndrome • Cerebrospinal fluid leak • Chronic liver disease • Cochlear implant • An immunocompromising condition • Congenital or acquired asplenia, or splenic dysfunction • Congenital or acquired immunodeficiency • Diseases or conditions treated with immunosuppressive drugs or radiation therapy • HIV infection • Sickle cell disease or other hemoglobinopathyTdap Vaccine Consent I have read the following recommendations and should receive my Tdap vaccine at this time:The Tdap vaccine protects against Tetanus, Diphtheria, and Pertussis. Tetanus (Lockjaw) is an infection caused by bacterial spores found in soil and dust everywhere; spores enter the body through wounds or broken skin. Diphtheria is a contagious viral infection of the nose, throat, and sometimes lungs. Pertussis (Whooping Cough) is a contagious bacterial infection of the lungs and airway that is especially dangerous for babies. Adults staying up to date helps protect babies who have not yet been vaccinated or don't have full protection yet. The CDC recommends that adults 19 and older get a single dose of the Tdap vaccine, and then receive a booster dose every 10 years, a booster dose with every pregnancy between weeks 27 and 36, and 5-10 years after your last booster if you receive a serious injury. 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 attestAll 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)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature(Required)
