Flu Shot Application Consent for Flu Vaccine （流感疫苗知情同意书）Please enable JavaScript in your browser to complete this form.Please complete the form below and we will contact you to schedule an exact date and time for your drive-through flu shot. (请完成填写下面的表格，我们会联系您，根据您所提供的信息确定流感疫苗注射日期和时间。） Personal and Contact Information （个人信息）Patient Status （注册情况） *Existing Patient （已注册病人）New Patient （新病人）Name (姓名） *FirstLastBirthdate （生日） *Age (年龄） *Gender (as shown on your passport) （性别--护照上显示性别） *Male （男）Female （女）Address （现住址--美国当地） *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number（联系电话） *Email（邮件） *Payment Information （付款信息）Insurance （保险） *No Insurance/ Cash （无保险，自费）BCBS/ CarefirstAetnaUnited HealthcareMedicare （Part B）OtherID(scanned) （驾照或护照扫描件或照片） * Click or drag a file to this area to upload. Insurance card(scanned) （保险卡扫描件或照片） * Click or drag a file to this area to upload. Cash pay patient, please upload ID again. （自费病人请再次上传证件照片）Questionnaire（问卷）1. Do you have a history of Guilain-Barre Syndrom? （您是否患有格林-巴利综合征/ 感染性多发性神经根炎？） *Yes （是）No（否）2. Do you have an acute illness with a fever now? （您目前是否患有急性病导致发烧？） *Yes （是）No （否）If yes, you should not receive vaccines today. （如果您正在发烧，今天请不要打流感疫苗。）3. Have you ever had a severe allergic reaction to seafood? （您是否对海鲜严重过敏？） *Yes （是）No （否） If yes, you should not receive a Flucelvax vaccine. （如果是，请不要打Flucelvax 这种流感疫苗。）4. Have you ever received a flu shot? （您以前打过流感疫苗吗？） *Yes （是）No （否） 5. Have you ever had severe reaction from a flu shot? （您以前有过因为打流感疫苗出现严重不良反应吗？） *Yes （是）No （否） Severe Reaction Date due to flu shot（由于打流感疫苗出现严重不良反应的日期）Consent and Release Statement（知情同意书） Please read the latest information about the 2020-2021 seasonal flu shot from the U.S. Centers for Disease Control (CDC) by clicking the link below. CCD Seasonal Flu Shot InformationCheckboxes *I have read and understand the CDC Information about the 2020-2021 Seasonal Flu Shot. （我已经阅读了CDC 2020-2021年流感疫苗的信息。）I have read and understand the benefits and risks of the vaccines and request that these be given to me or to the minor named above for whom I am authorized to make this request. The vaccine will be administered by a registered or licensed practical nurse or nurse practitioner. I understand that if I have a reaction, I am to consult my physician. （我已阅读并理解了疫苗的益处和风险，并要求将其提供给我或我授权的上述未成年人。疫苗将由护士/护师等专业从业人员进行注射。我了解如果我有不良反应，我将咨询我的医生。） Flu Shot Administer Agreement *I agree to receive Flu Shot. （我同意注射流感疫苗。）Preferred date and time for flu shot *DateTimeComment or Message （留言）Captcha * = PhoneSubmit （提交）
