The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

ev5wabsCaF9NCgHb7hvEZupuf6MrQa3yGWuoYD7A4Z7HM4c8SJyqSp9dQdBExR8uZhEZdgMUj3rZarebVZxeytrVGtEjuHR7Fft6yQu5EtfFMSAssv

Influenza Screening & Consent

Community-based, influenza vaccination clinics are being held in partnership with the USC Pharmacies, USC School of Pharmacy, Los Angeles City/Office of Mayor Eric Garcetti, Los Angeles County Department of Public Health, Los Angeles Fire Department, and CORE.

Please complete the form below for the 2020-2021 Flu Vaccination. Thank you!

Complete el cuestionario para la vacuna contra la influenza 2020-2021. ¡Gracias!

Today's Date /

Fecha

* must provide value

M-D-Y

Last Name /

Apellido

* must provide value

First Name /

Primer Nombre

* must provide value

Middle Initial /

Inicial del segundo nombre

Sex /

Sexo

* must provide value

Male

Female

Other

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[Optional] Last 4 of Social Security Number. This will help us find your insurance information. /

[Opcional] Últimos 4 dígitos de su número de seguro social. Esta información nos ayudará a encontrar la información de su seguro médico.

Date of Birth (MM/DD/YYYY) /

Fecha de nacimiento

* must provide value

M-D-Y

Age (years) /

Edad (en años)

* must provide value

View equation

Address /

Dirección de envio (Número y nombre de la calle)

* must provide value

City /

Ciudad

* must provide value

Zip Code /

Código postal

* must provide value

Phone Number /

Número de teléfono

* must provide value

Email Address /

Dirección de correo electrónico

This will be used to send you confirmation emails and records of your vaccinations. /
Esto se utilizará para enviarle correos electrónicos de confirmación y registros de sus vacunas.

The following information is requested to report to the California Immunization Registry (CAIR): Mother's First Name

Se solicita la siguiente información para informar al Registro de Vacunas de California (CAIR): Nombre de la madre

Race/Ethnicity (choose one) /

Raza / Etnia (seleccione uno)

* must provide value

American Indian / Alaskan Native

Asian

Black / African-American

Latino

Multiracial

Native Hawaiian / Pac. Islander

White

Other

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What type of health insurance do you have?

¿Qué tipo de seguro médico tienes?

* must provide value

Medi-Cal/Medicaid

Medicare

Private Insurance (ex. Anthem, Blue Cross) / Seguro privado

Kaiser Permanente

Other insurance / Otro seguro

None / Ninguno

I don't know / Yo no sé

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[Optional] Please upload a photo or copy of the FRONT of your health insurance card.

[Opcional] Sube una foto o copia del ANTERIOR de tu tarjeta de seguro médico.

Upload file

Please upload a photo or copy of the BACK of your health insurance card.

Sube una foto o copia del REVERSO de tu tarjeta de seguro médico.

Upload file

Yes

Not Sure

Have you EVER received a flu shot (anytime before July 1, 2020)? / ¿Alguna vez recibió una vacuna contra la influenza (en cualquier momento antes del 1 de julio de 2020)?

* must provide value

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Do you have a fever or are you sick today? / ¿Tiene fiebre o está enfermo hoy?

* must provide value

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Are you pregnant or do you think you may be pregnant? / ¿Está embarazada o cree que puede estarlo?

* must provide value

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Have you had a serious reaction to flu vaccine requiring medical help? / ¿Ha tenido una reacción grave a la vacuna contra la gripe que requiera ayuda médica?

* must provide value

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Do you have a severe allergy to eggs? / ¿Tiene una alergia grave a los huevos?

* must provide value

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Do you have an allergy to thimerosal? / ¿Tiene alergia al timerosal?

* must provide value

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Have you ever had Guillain-Barré Syndrome (GBS)? / ¿Ha tenido alguna vez el síndrome de Guillain-Barré (GBS)?

* must provide value

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If signed by another other than the patient, please mark the box below to describe your relationship to the patient.

Si está firmado por otra persona que no sea el paciente, marque la casilla a continuación para describir su relación con el paciente.

Self

Parent

Guardian

Healthcare Agent

Other Authorized Individual

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