Influenza Vaccine Consent Form

Influenza Vaccine Consent Form
Section I. Personal Information
Patient's Full Name *

First NameMiddle NameLast Name
Mother's Maiden Name *
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Email:*
Gender:*

MaleFemale
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answer
Address:*

Street Address Line 2
Primary Care Doctor:
Doctor City/State:
Preferred Pharmacy*
I am interested in the following vaccinations: (check all that apply)*

Influenza Vaccine
Flu - https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf
Insurance Information
Medicare Information
Commercial Insurance
Insured Patients

I authorize the pharmacy to bill my insurance on my behalf for the immunization
If uninsured, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan
Section II. Screening for Immunization
Does the person to be vaccinated have a fever or illness today?*

YesNo
Does the person to be vaccinated have an allergy to eggs, latex, or to a component of the vaccine?*

YesNo
Has the person to be vaccinated ever had a serious reaction to this vaccine in the past?*

YesNo
Has the person to be vaccinated ever had Guillain-Barre syndrome less than 6 weeks after vaccination, uncontrolled seizures or any unstable neurological disorder?*

YesNo
Has the person to be vaccinated received any vaccines in the past 30 days?*

YesNo
Is the person to be vaccinated 6 years of age or older?*

YesNo
Is the person to be vaccinated currently pregnant, breastfeeding, or planning to become pregnant in the next 30 days?*

YesNo
Section III. Consent for Immunization
I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving today. All my questions concerning the vaccine have been answered to my satisfaction. I understand the benefits and risks of receiving the vaccine and request that it be given to me. I ask that this vaccine be administered by pharmacist, pharmacy intern, or pharmacy technician. I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)*

Clear
Parent/Guardian Name (if applicable)

First NameLast Name
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Should be Empty: