Influenza Vaccine Consent Form

Section I. Personal Information

Patient's Full Name *

First Name Middle Name Last Name

Mother's Maiden Name *

Date of Birth: *

Age: *

Phone Number: *

Email: *

Gender: *

Male Female

Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer 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? *

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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 Name Last 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.