Remember Your Shot and forget the Flu

Transcription

1 Remember Your Shot and forget the Flu Ascension Borgess Flu and Pneumonia Vaccine Clinics 2018 Flu shots are recommended every year for everyone over six months of age. Borgess Health provides over one hundred flu and pneumonia vaccine clinics throughout southwest Michigan during September and October. On the next pages is a listing by county of the clinics scheduled this year. You do not need an appointment - patients are taken on a first come, first served basis. Vaccines Available Flu Vaccines Pneumonia Vaccines Trivalent (5 years and up) Pneumovax 23 (19 years and up) Quadrivalent (6 months and up) Prevnar 13 (19 years and up) FluMist Nasal Spray (2 years through 17 years) If you are unsure of which vaccine to choose, please talk with your primary care provider. Insurances Accepted Medicare Part B (including Medicare Advantage plans) Most commercial insurances We are unable to accept Medicaid insurances since current regulations do not allow coverage for mass immunization clinics. These include, but are not limited to, Medicaid, Healthy Michigan Plan, Cofinity NGS-Bronson Employees or any Medicaid HMO plans (e.g., Meridian, McLaren Health Plan, United Healthcare Community Plan, Priority Health and Coventry Cares). Patients with Medicaid or Medicaid HMO coverage should call their primary care physician and schedule an appointment to have their flu immunization. For anyone without insurance, we offer a discount for payment by cash or check at the time of service. We are not able to accept credit or debit cards. $29 Trivalent Flu $90 Pneumovax 23 $38 Quadrivalent Flu $135 Prevnar 13 $38 FluMist Nasal Spray Informed Consent form On the last page is a flu immunization Informed Consent. You may complete this form at home and bring it with you to the clinic you choose to attend. There will be additional copies at the clinics as well as informed consents for the other vaccines listed above. Any questions you have when completing the form can be addressed when you arrive at the clinic. For additional information, call or visit ascension.org/flushotkalamazoo (website will be live soon)

2 List of clinics by county No appointments necessary Allegan County Tuesday, September 11 Allegan County Fair Senior Day Hilltop Community Tent, Allegan 7:30-11am Wednesday, September 12 Borgess Pipp Hospital 411 Naomi St, Plainwell 9-11:30am Grand Ravine Senior Housing 725 Grand Ravine Dr, Allegan 1:30-3:30pm Wednesday, September 19 Allegan County Health Dept nd Ave, Allegan Thursday, September 20 St. Peter Catholic Church 100 St Peter Dr, Douglas 11:30am-1:30pm Harbor Senior Apartments 67 Wiley Court, Fennville 2:30-4pm Monday, September 24 Rivers Run Apartments 515 Streeter Ave, Allegan 11:30am-1pm Baraga Manor 301 Washington St, Otsego 2:30-4:30pm Thursday, September 27 Otsego Public Library 401 Dix Street, Otsego Thursday, October 4 Allegan Public Schools th St, Allegan 1-6pm Borgess Pipp Hospital 411 Naomi St, Plainwell 2pm-4pm Thursday, October 11 Plainwell Community Center 798 E Bridge St, Plainwell 9-11am Ganges United Methodist Church th Street, Fennville 1-3pm Wednesday, October Reno Drive, Wayland Thursday, October 18 Allegan County Health Dept nd Ave, Allegan 1:30-3:30pm Monday, October 22 First Presbyterian Church 303 E Bridge St, Plainwell 9am-11am Tuesday, October 23 Saints Cyril & Methodius Church st Ave, Wayland 3:30pm-6pm Berrien County Wednesday, September Mars St, Berrien Springs Wednesday, October Shawnee Rd, Bridgman Calhoun County Wednesday, September 19 Borgess Health Park 3035 Capital Ave, Battle Creek 4-6pm Saturday, October 13 Borgess Health Park 3035 Capital Ave, Battle Creek Receive your flu shot without leaving your vehicle Cass County Saturday, October 6 Borgess Lee Memorial-Drive Thru 420 West High Street, Dowagiac Kalamazoo County Thursday, September 6 Weatherstone Village 5210 Marsh Arbor Trail, Kalamazoo Saturday, September 8 Gull Lake United Methodist Church 8640 Gull Road, Richland 9am-11am Monday, September 10 Royal Estates 8300 Ravine Road, Kalamazoo 9am-11am Parchment Community Library 401 S Riverview Dr, Parchment Oshtemo Charter Township Hall 7275 West Main Street, Kalamazoo 1:30-3:30pm Thursday, September 13 YMCA 1001 W. Maple Street, Kalamazoo 8:30am-11:30am Comstock Towers 5285 E. H Ave, Kalamazoo 9-11am Saturday, September 15 Borgess Health & Fitness Center 3025 Gull Road, Kalamazoo Sunday, September 16 Lutheran Church of the Savior 3616 East G Avenue, Kalamazoo 11am-12noon

3 Kalamazoo County cont d Tuesday, September 18 VanderSalms Flower Shop 1120 S. Burdick St, Kalamazoo Wednesday, September 19 Kalamazoo Public Library 315 S. Rose Street, Kalamazoo 11:30am-1:30pm Thursday, September 20 Texas Township Hall 7110 W Q Ave, Kalamazoo 12noon-2pm Friday, September 21 Richland Area Community Center 9400 East CD Ave, Richland Cedar Park Senior Housing 474 N. Cedar, Schoolcraft 2-3pm Sunday, September 23 Pathfinder Church 8740 S. Westnedge Ave, Portage 8:15-11am Galesburg United Methodist Church 111 W. Battle Creek St, Galesburg 11:45am-1pm Monday, September 24 Borgess Health and Fitness Center 3025 Gull Road, Kalamazoo Tuesday, September 25 YMCA (A Frame Bldg) 2900 W Centre Ave, Portage Wednesday, September 26 Westside Family Medicine 6565 West Main St, Kalamazoo 10:30am-12:30pm Spring Valley Crossings Apartments 2535 Mount Olivet, Kalamazoo 12:30-1:30pm 54 West Michigan, Galesburg 1-3pm Thursday, September 27 Parkview Hills-Willow Lake Clubhouse 3707 Greenleaf Circle, Kalamazoo 9-11am AND 4-6pm Kalamazoo Air Zoo 6151 Portage Road, Portage 12:30-2:30pm Friday, September 28 Country Acres Village 2300 Barney Road, Kalamazoo Portage Senior Center 320 Library Lane, Portage 3-6pm Saturday, September 29 Sunday, September 30 First United Methodist Church 212 South Park St, Kalamazoo 9:30am-11am Monday, October 1 Oshtemo Charter Township Hall 7275 West Main St, Kalamazoo 10am-1pm Tuesday, October 2 Kalamazoo County Senior Expo Expo Center and Fairgrounds 2900 Lake St, Kalamazoo 9am-3pm Wednesday, October Gull Road, Richland 1000 E. Cork St, Kalamazoo 12noon-2pm Friday, October 5 Richland Area Community Center 9400 East CD Ave, Richland Saturday, October 6 Westside Family Medicine 6565 West Main St, Kalamazoo St Catherine Catholic Church 1150 W Centre Ave, Portage 3-5pm Sunday, October 7 Portage Chapel Hill UM Church 7028 Oakland Dr, Portage 9am-12:30pm Monday, October 8 Portage Chapel Hill UM Church 7028 Oakland Dr, Portage Tuesday, October 9 Comstock Community Center 6330 Kings Highway, Kalamazoo First Presbyterian Church 224 E. Cass St, Schoolcraft Wednesday, October 10 Zion Lutheran Church 2122 Bronson Blvd, Kalamazoo 9-11:30am Thursday, October 11 Borgess Health & Fitness Center 3025 Gull Road, Kalamazoo 3-6pm Friday, October 12 St. Monica Catholic Church 534 W. Kilgore Ave, Kalamazoo Saturday, October 13 Sunday, October 14 St. Joseph Catholic Church 936 Lake St, Kalamazoo Monday, October 15 Milwood United Methodist Church 3919 Portage Rd, Kalamazoo 9-11am Tuesday, October 16 YMCA 1001 Maple Street, Kalamazoo 12noon-3pm

4 Kalamazoo County cont d Wednesday, October 17 YMCA 2900 W. Centre Ave, Portage 1:30-4pm Thursday, October Gull Road, Richland 1-3pm Friday, October 19 United Way of Battle Creek/Kalamazoo 709 S. Westnedge, Kalamazoo Sunday, October 21 Southridge Reformed Church 6726 Texas Drive, Kalamazoo Wednesday, October 24 Fountain Springs 1410 S. 9 th St, Kalamazoo Saturday, October 27 St. Joseph County Sunday, October 7 Centreville United Methodist Church 305 E Main, Centreville Monday, October 8 Constantine Public Library 165 Canaris St., Constantine Tuesday, October 16 Mendon Township Library 314 West Main St, Mendon Van Buren County Wednesdeay, September North Center St., Hartford Peace Evangelical Lutheran Church Blue Star Highway, South Haven 9:30-11am

5 Please Print: Ascension Borgess Flu Immunization Informed Consent 9 years and up Please complete back side of page Last Name First Name Middle Initial Street Address City State Zip code - - Sex Date of Birth Age Phone Number Male Female Address (optional) This section only for: Traditional Medicare patients (red, white and blue card) Patient has traditional Medicare Part B as the primary insurance Medicare Number (include letter) Please keep your card out for verification ======================================================================================================== This section only for: Medicare Advantage (non-traditional) patients Patient does NOT have Medicare Part B as the primary insurance, but has a Medicare Advantage plan (complete the information below). Please use the card that you give to your physician or for hospital visits. Your drug plan or your supplemental coverage plan does not pay for the flu immunization. Please keep your card out for verification Medicare Advantage Name Member ID Number Group Number (if available) I understand that Borgess will bill my Medicare plan; however, I accept full responsibility for any charges not covered by my Medicare Plan. This section only for: Other Insurance patients Relationship to insured: Self Spouse Child Insured s Name Insured s Date of Birth Name of Insurance Provider Network Group Number Policy Number BORGESS STAFF USE ONLY Amount paid: Payment method: Cash Check # Bill Patient Billing/payment information verified by (Staff initials)

6 Borgess Flu Immunization Informed Consent 9 years and up Patient Name Please circle the correct answer on the right 1. Have you ever had a flu shot? No Yes 2. Have you ever had a life-threatening reaction to a flu shot? No Yes 3. Are you running a temperature of 101 o F or over? No Yes 4. Are you severely allergic to eggs, egg products, chicken, chicken feathers or chicken dander? No Yes 5. Do you have a known allergy to contact lens solution or thimerosal (a mercury derivative)? No Yes 6. Have you ever been paralyzed by Guillain Barre Syndrome? No Yes 7. Females only: Are you or could you be pregnant? No Yes If yes, has your physician recommended that you receive a flu shot? No Yes 8. Have you ever received a pneumonia vaccine? When? No Yes I have read and received a copy of the Inactivated Influenza Vaccine Information Statement prior to my vaccination. I understand the risks and benefits involved. I have had a chance to ask questions and you answered them to my satisfaction. I want you to give the vaccine to me. I agree to stay in the general area for fifteen (15) minutes after receiving my vaccination. This is to watch for any reaction that may occur right away. We can t ensure that immediate reactions will not occur. I understand that if I experience any unusual or severe side effects, it will be my responsibility to seek emergent care or follow up with my personal physician at my expense. The Ascension Borgess Notice of Privacy Practices gives you information about how we use and disclose medical information about you. By signing this form, you are acknowledging that a copy was made available to you. Per Michigan Law, I am aware that Borgess may test my blood for HIV (AIDS virus), Hepatitis or other infectious diseases if a health care worker is exposed to my blood or body fluids during this vaccination process. I agree to reimburse Ascension Borgess if my medical insurance plan rejects payment. Signature of person receiving vaccine. If under 18 years of age or physically unable, the person authorized to make this request for patient listed above. Relationship to person receiving vaccine if patient not signing Date Time ASCENSION BORGESS STAFF USE ONLY Administered by Nurse Signature / Title Date Time Trivalent Seqirus Afluria Sanofi Fluzone High Dose (65 years and up) Quadrivalent GSK Flulaval GSK Fluarix Injection Site: Deltoid 0.5ml, IM Left Right Lot Code: A B C D E F G H I J K