Influenza Vaccine Screening Questionnaire
For vaccine recipients: Please answer the following questions. If the questions are unclear, please ask your healthcare provider. A parent must complete the form for children < 18 years of age.
STOP: Please only complete the questions below if you want to receive FluMist instead of the flu vaccine.
CONSENT FOR VACCINATION: I have read, or have had explained to me, the Vaccine Information Statement for the vaccine (www.OCPH.info I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the Flu vaccine be given to the person named above for whom I am authorized to make this request. I understand that a record of this immunization may be shared through the Wisconsin Immunization Registry (WIR) and with other health care providers directly involved with the vaccinated person's care. A copy of this consent form is as valid as the original.