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Influenza Vaccine Consent Form - Motorola Solutions Mobile App

This mobile app from Inova Health System checks consent from a specified patient concerning their Influenza vaccine. It marks the patient’s granted permission to be given the listed vaccine(s), and also declaration about past or present allergies and sicknesses. This app has screens that capture personal information, signature and payment method. This app works on a variety of Motorola Solutions devices, including the ES400 and ET1.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Influenza Vaccine Consent Form - Motorola Solutions Mobile App

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Included Fields

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    INOVA HEALTH SYSTEM 2700 Prospericy Avenue, Suite 100, Fairfax, VA 2203

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    CLINIC

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    I hereby give my consent, voluntarily and of my own free will, to the staff of Inova Health Syste...

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    containing A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, B/Brisbane/60/2008-like.

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    I have read and understood “What To Do If You Have A Reaction To The Flu Shot.

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    These “seasonal” influenza vaccines are formulated to prevent annual flu.

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    I declare that I am over the age 18.

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    I am not allergic to chicken eggs.

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    I have not had Guillain-Barre syndrome or other reactions listed below from the previous vaccina...

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    I am not now sick with a fever or active respiratory infection.

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    I am not allergic to thimerosal or other mercury compounds.

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    5. I am not allergic to gentamicim, neomycin or other aminoglycoside antibiotics

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    I understand I could be at risk of having a negative reaction and therefore, I should not have it.

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    Medicare Part B Participants: I understand Inova Health System Foundation and/or its affiliates w...

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    claims on my behalf and accepts Medicare payment in full.

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    I understand that if I have assigned my Medicare benefits to an HMO/managed care plan,

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    I must receive my flu shot from my HMO/managed care provider or pay the Inova Health System charge.

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    I understand Medicare Part B.

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    I understand that the risks associated with influenza vaccine include, but are not limited to, pa...

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    or nerve pain, headache, fever, paralysis or Guillain-Barre syndrome (a kind of paralysis), encep...

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    (including anaphylactic shock or death).

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    I also understand that it is not possible to predict all possible side effects or complications w...

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    I understand that the risks associated with influenza vaccine.

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    I understand the the vaccination is being given by Inova Health System.

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    The owner and/or operator of this site, their affiliates, officers, directors, employees and agents

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    expressly disclaim any responsibility to the vaccination procedure.

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    My consent is given in light of this knowledge, and in consideration of Inova Health System givin...

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    I, for myself and my heirs, administrators, trustees, executors,

  • ...and More!

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