Turnstone Vaccination Consent Turnstone Vaccination Clinic on September 22, 2025 Step 1 of 5 - Event 0% Please fill out all sections of the form completely, including your personal details and insurance information. Don’t forget to sign and date the form at the end before submitting. We look forward to seeing you on October 7th. Should you require any assistance, please don’t hesitate to contact us at Emilie.Singleton@supershot.org Patient’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 answerWhat gender do you identify with?(Required)Select OneMaleFemaleNon-BinaryOtherPrefer not to answerSexual 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 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 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 ConsentI consent to receiving Vaccination services from Super Shot.(Required) Yes No I would like Super Shot to administer the following vaccines:(Required) Influenza High Dose Flu (65+) Updated COVID-19 Tdap HPV - recommended for individuals 45yo or younger Pneumonia - recommended for individuals age 65+ RSV - recommended for individuals age 75+ and 50-74yo with risk factors as well as pregnant women 32-36 weeks gestation Shingles - recommended for age 50+ I have read the following recommendation and should receive my Tdap vaccine at this time: I agreeThe 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.I have read the following recommendation and would like to receive my HPV vaccine at this time: I agreeThe HPV (human papillomavirus) vaccine can prevent infection from some types of human papillomavirus. HPV infections can cause certain types of cancers, including: • cancers of tonsils, base of tongue, and back of throat (oropharyngeal cancer) in both men and women • cervical, vaginal, and vulvar cancers in women • penile cancer in men • anal cancers in both men and women HPV infections can also cause anogenital warts. The HPV vaccine can prevent over 90% of cancers caused by HPV. The HPV vaccine may be given beginning at age 9 years and is recommended for everyone through 26 years of age. The HPV vaccine may be given to adults 27 through 45 years of age, based on discussions between the patient and health care provider. Please speak to your PCP or call Super Shot at (260)424.7468 if you have any questions.I have read the following recommendation and should receive my Pneumococcal vaccine at this time: I agreeThe Pneumococcal vaccine is indicated for adults 50+ who have not previously completed their pneumococcal series or ages 19-49 with the following conditions: • 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 hemoglobinopathy Please speak to your PCP or call Super Shot at (260)424.7468 if you have any questions.I have read the following recommendation and should receive my RSV vaccine at this time: I agreeThe RSV vaccine is indicated for adults 75+ who have not previously received it or ages 50-74 with the following conditions: • Chronic heart disease o Including: heart failure, coronary artery disease, or congenital heart disease o Excluding isolated hypertension • Chronic lung or respiratory disease o Including: chronic obstructive pulmonary disease, emphysema, asthma, interstitial lung disease, or cystic fibrosis • End-stage renal disease or dependence on hemodialysis or other renal replacement therapy • Diabetes mellitus complicated by chronic kidney disease, neuropathy, retinopathy, or other end-organ damage, or requiring treatment with insulin or sodium-glucose cotransporter-2 (SGLT2) inhibitor • Neurologic or neuromuscular conditions causing impaired airway clearance or respiratory muscle weakness o Including: poststroke dysphagia, amyotrophic lateral sclerosis, or muscular dystrophy o Excluding: history of stroke without impaired airway clearance • Chronic liver disease • Chronic hematologic conditions o Including: sickle cell disease or thalassemia • Severe obesity (body mass index ≥40 kg/m2) • An immunocompromising condition • Residence in a nursing home • Other chronic medical conditions or risk factors that a health care provider determines would increase the risk for severe disease due to viral respiratory infection The RSV vaccine is recommended by the CDC for pregnant women between 32-36 weeks of pregnancy to protect the newborn baby after birth. Please speak to your PCP or call Super Shot at (260)424.7468 if you have any questions.I have read the following recommendation and should receive my Shingkes vaccine at this time: I agreeThe Shingles vaccine is indicated for adults 50+ who have not previously completed their shingles series or ages 19-49 with a weakened immune systems due to disease or therapy. Please speak to your PCP or call Super Shot at (260)424.7468 if you have any questions.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 agreeAll information I have provided on the consent for vaccination is true and correct. I am aware the HIPAA Notice of Privacy Policy is available at supershot.org. I am aware and understand that the CDC Vaccine Information Statements (VIS) for the vaccines the patient will receive today are 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. 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)Phone
