Flu Vaccine-INJECTION
Please Note that this Consent is only for the Flu injection NOT the Nasal Flu
Are You Currently or Previously associated with our office? Please check below
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Dr. Kahn
Dr. Garrison
other
No Previous Association
Patients First/Last Name:
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Age
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Gender
*
Male
Female
Do you have a severe allergic reaction to eggs?
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YES
NO
Has Anyone in your household been exposed to COVID-19 in the past 14 days?
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YES
NO
Is Anyone in your household awaiting results of COVID-19 testing?
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YES
NO
Have You ever been diagnosed with Guillian-Barre' syndrome?
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YES
NO
Do you feel ill or have a fever/sore throat?
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YES
NO
Have you ever had an allergic reaction to a previous flu vaccine?
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YES
NO
Age of Consent
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I hereby declare that I am of legal age and I give my consent with full knowledge and responsibility to the risks and benefits of the vaccine. I have had the opportunity to ask questions and which answers were given to me to my satisfaction.
I am the legal representative of the above-named patient. The patient is of legal age and I am executing this document on his/her behalf. He/she have had the opportunity to ask questions and which the answers were provided to him/her to his/her satisfaction.
I am the legal guardian of the above-named patient. I am executing this document on his/her behalf with my full consent and authority. I have had the opportunity to ask questions and by which answers were given to me to my satsifaction.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
For Medical Staff to Complete:
LOT#:
SITE:
GIVEN BY:
DATE/TIME:
Submit
Should be Empty: