2022-2023 Influenza Vaccine Consent Form

Timing:- 9:00 AM to 12:00 PM

* 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: AS4503A Exp: 06/30/2023

Site of Administration:       Deltoid

Accubills Healthcare Solutions
Plot #C-210 CA, Phase 8B,
Industrial Area, Sector 74, Sahibzada Ajit Singh Nagar,
Punjab 160055

sales@accubills.com, hr@accubills.com

www.accubills.com

Fax - 1-(888)-480-5959

Contact Numbers - +1-(914)-339-2685 ,
+1- (914)-343-1147 , +91- 62841-28574

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