Consent For Services Step 1 of 7 - Event 14% Vaccination Event:Who is receiving the vaccination(Required)Select OneChild (18 and under)Adult (19 and over)Vaccination Event(Required)Select Super Shot EventDecline Vaccine I DO NOT want my child to receive a vaccine at schoolPlease complete this first section and submit the form.Child's Name(Required) First Last Child's Date of birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's School Name(Required) Child's Grade(Required)Select Child's GradePre-KK123456789101112 Patient’s Information:School Name(Required) Child's Grade(Required)Select Child's GradePre-KK123456789101112Patient Name(Required) First Middle Inital Last Suffix Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Sex(Required)Select OneMaleFemaleRace(Required)Select OneWhiteAfrican AmericanAsianHispanicAmerican IndianNatl. Hawaiian, Pac IslAlaskan NativeOtherAddress(Required) City(Required) State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip(Required) Contact Information:Parents/Guardians(Required)First NameMiddle NameLast NameSuffix Add RemoveMaiden Name of Child’s Mother(Required) Mobile Phone Number(Required)Home Phone Number(Required)Email Address(Required) Contact Preference(Required)Select OneMobile PhoneHome PhoneTXT MessageEmail Required Health Insurance Information:Select One(Required) Private Insurance Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise) No Insurance: I certify that the patient is not covered by any health insurance. Patient’s Primary Care Provider(Required) Insurance Company(Required) Member ID(Required) Group #(Required) Policy HolderName First Middle Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer(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. Demographic Information:Number of people in household(Required)Current annual household income(Required) Medical Information:Please select Yes or No for all questions. Answers are for the person getting the vaccine.Is the patient allergic to anything? (if yes, please note)(Required) Yes No List all allergies(Required) Add RemoveHas the patient had a serious reaction to a vaccine in the past?(Required) Yes No Is the patient pregnant or is could they become pregnant within a month of being vaccinated?(Required) Yes No Is the patient on aspirin therapy or blood thinners?(Required) Yes No Has the patient, a sibling, or a parent had a seizure? (if yes, please explain)(Required) Yes No Explanation of seizure(Required) Will the patient be on antivirals within 3 weeks of vaccination?(Required) Yes No Does the patient live or have close contact with someone who is severely immunocompromised or requires a protective environment?(Required) Yes No Does the patient have any of the following: (mark all that apply)(Required) Chronic Heart Disease Kidney Disease Liver Disease Complement ComponentDeficiency 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 ConsentCommunication It's ok to call me It's ok to TXT me Medical It’s ok to submit my records to CHIRP 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 give the patient the vaccine in my absence, 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.Signature(Required)Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920