By scheduling an appointment for the Influenza Vaccine, I hereby acknowledge that I have received and reviewed the Influenza Vaccine Information Sheet.
Are you a current Bronson employee?
Community vaccine clinics are billed to insurance. These are not Bronson ProHealth events. Your insurance will be billed for the vaccine if you come through the community vaccine clinics.
Are you eligible for the Vaccine for Children Program?
Children through 18 years of age who meet at least one of the following criteria are eligible to receive VFC vaccine:
Medicaid eligible: A child who is eligible for the Medicaid program. (For the purposes of the VFC program, the terms “Medicaid-eligible” and “Medicaid-enrolled” are equivalent and refer to children who have health insurance covered by a state Medicaid program)
Uninsured: A child who has no health insurance coverage
American Indian or Alaska Native: As defined by the Indian Health Care Improvement Act (25 U.S.C. 1603)
Children whose health insurance covers the cost of vaccinations are not eligible for VFC vaccines, even when a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier because the plan’s deductible had not been met.
Please refer to the CDC website for detailed guidelines of qualification.
Would you also like your COVID-19 Vaccine during this visit?
Which Covid vaccination dose do you need to schedule?
By scheduling an appointment for the COVID-19 Vaccine, I hereby acknowledge that I have received and reviewed the COVID-19 Vaccine Fact Sheets.
Have you had a severe allergic reaction to a vaccine or injectable therapy?
(IM, IV, Subcutaneous)
It is recommended, if you have had a severe allergic reaction to a vaccine or injectable therapy (IM, IV, subcutaneous) you should consult with your healthcare provider before receiving the COVID-19 vaccine. It is required that you be observed for 30 minutes following vaccination.
Have you been given monoclonal antibodies or convalescent plasma as part of COVID-19 treatment in the last 90 days?
Choose your age range:
Consent for administration of the vaccine is required for everyone. For those under 18 years old, a parent or legal guardian must provide consent. For 12-15 year olds, an adult must accompany the patient to the clinic. If the adult present is not the parent or legal guardian, an authorization form must be signed by the parent or legal guardian and that paper consent must be brought to the appointment.
Consent for administration of the vaccine is required for everyone. For those under 18 years old, a parent or legal guardian must provide consent. For 16-17 year olds, if a parent or legal guardian does not accompany the patient to the clinic, an authorization form must be signed by the parent or legal guardian and patient must bring the paper consent to the appointment.