Flu Vaccine Consent and Administration Record--Inverness
Date of Vaccine Administration
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Name
Date of Birth
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Local Address
Street Address Line 2
City
State / Province
Zip
Local Phone
Format: (000) 000-0000.
Email
example@example.com
ADMINISTRATION QUESTIONS:
Have you ever had a serious allergic reaction to a flu vaccine?
No
Yes
Have you ever had a serious allergic reaction to eggs or gelatin?
No
Yes
Do you, or have you ever, had Guilliane-Barre syndrome?
No
Yes
In the past 5 years, has a physician or other health care provider instructed you to NOT get a flu vaccine?
No
Yes
Have you had a fever over 100 in the past 48 hours?
No
Yes
Do you currently have a moderate or severe acute illness? (Pneumonia, etc)
No
Yes
Are you interested in any additional vaccines today, such as pneumonia, covid, shingles, or tetanus?
No
Yes
What vaccines are you interested in?
Shingles
Pneumonia
Covid
Tetanus
RSV
This is the Vaccine Information Sheet. You may request a paper copy from the pharmacy staff if you prefer a paper copy. You can also download this form to your phone for later access, or you may find it online at www.cdc.gov The next question pertains to this form.
Have you received and read a Vaccine Information Sheet about the flu vaccine?
No
Yes
Into which arm would you like us to administer your flu vaccine?
Right Arm
Left Arm
If you give your consent to receive the flu vaccine, please sign below.
When was your last flu vaccine, approximately?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: