• Vaccination Consent Form

    Vaccination Consent Form

    Flu/Other vaccines
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth of person receiving vaccine*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Has the Patient Had a Flu Shot Before?

  • Screening for Vaccine Eligibility

    The following questions will help us to know if you get the seasonal influenza vaccine. If you answer “NO” to all of the following questions, you can get the influenza vaccine.  If you answer “YES” to one or more of the following questions, we will discuss your options for the flu shot. 

  • Please mark YES or NO for each question. 

  • 1. Does the patient have a serious allergy to eggs or chickens?*
  • 3. Has the patient ever had a serious reaction to a previous dose of flu or other vaccine?*
  • 4. Has the patient ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness)?*
  • 5. Does the patient currently feel ill?*
  • 6. Has the patient had a fever in the last 24 hours?*
  • Check box that correspond to your situation:*
  • I understand that if my insurance is not accepted via VAXCARE then I am responsible for payment for the specific vaccination given and will pay prior to leaving. Dr. Davidson has notified me of this prior to the visit as well. Influenza injection and Flu mist is $45 and high dose Influenza for 65 years and older is $65.*
  • Vaccination patient is receiving (check all that apply)*

  • Vaccine Information Sheets

    1. Inactivated Flu Vaccine Injection: https://www.immunize.org/vis/flu_inactive.pdf

    2. Live Nasal Mist: https://www.immunize.org/vis/flu_live.pdf

    3. All other vaccinations: https://www.cdc.gov/vaccines/hcp/vis/current-vis.html

     

  • Consent for Vaccination

    I have read the most current Vaccine Information Statement published by the CDC for the seasonal influenza vaccine or other vaccine I am receiving today and understand the risks and benefits. I give consent for PRACTICE to administer the flu vaccine or other vaccine I have chosen today.   I understand Dr. Risa Davidson may not be my PCP therefore any questions must be directed toward my own primary care physician.
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