2021-2022 Influenza Vaccine Consent Form

Timing:- 8:30 AM to 10:30 AM / Thursday

* Fields are required to submit form

   

Are you allergic to eggs or egg products?  

Did you ever have Guillain-Barre' Syndrome?   

Are you sick or do you have a high fever today?   

Have you been sick in the past 2 weeks?   

Have you had a reaction to the flu shot?   

If yes,what type of reaction?

Do you have a blood clotting disorder or are you taking blood thinners?     

Acknowlegement and waiver:

I, the undersigned, wish to receive the vaccine described above. I have read and answered the above questions truthfully. I am taking the vaccine voluntarily and consent to the vaccination being given to me. I have read the vaccine information statement (VIS) provided and understand the risk and benefits of this vaccine

PARENTS/GUARDIANS SIGN BELOW ON BEHALF OF MINOR CHILDREN.

Office Use Only:

INFLUENZA

Dose: 0.5ml Brand Name: FLUCELVAX Lot: 308518 Exp: 06/30/2022

Site of Administration:       Deltoid