2022-2023 Influenza Vaccine Consent Form
Touchscreen (iPad/Phone) recommended for ease of signature capture
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Medicare Number or Social Security Number
Address
*
If individual, type in address & phone number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Care Provider
*
Dr.
Mr.
NP
PA
Prefix
First Name
Last Name
Is the person to be vaccinated sick today?
*
No
Yes
Does the person to be vaccinated have an allergy to an ingredient of the vaccine?
*
No
Yes
Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
*
Yes
No
I don't know
Have you ever fainted or had a serious reaction to any previous injection or vaccine(s) including Guillain- Barre Syndrome?
*
Yes
No
I have read or had explained to me and understand the benefits, side effects and risks of receiving and risks of not receiving the influenza vaccine.
I have had the opportunity to ask questions and I have received satisfactory answers.
I agree to be observed for at least 15 minutes after receiving the influenza vaccine or as directed, in the pharmacy or the clinic site by the pharmacists or staff.
I authorize my pharmacist to notify my physician/nurse practitioner and/or public health of the vaccine received, any adverse events experienced and/or to contact me with any follow-up if needed.
I consent to receive the influenza vaccine today OR
I consent on behalf of the patient to receive the influenza vaccine today.
Signature
*
Name of Signatory
*
Authorized Rep
Conservator
Caseworker
Family Member
Patient
Select Appropriate Title
First Name
Last Name
Email
A copy will be emailed to you.
Submit
Should be Empty: