CONSENT FOR VACCINATION
Please read the Vaccine Information Sheet (VIS) above for Influenza (Flu) Vaccine (Inactivated or Recombinant). If PDF does not appear, please visit https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf to view
ACKNOWLEDGEMENT
I have read or had explained to me the current Influenza Vaccine Information Statement (VIS). I understand the benefits and risks of the influenza vaccine, I have had the opportunity to disclose any related risks to the vaccine to the provider, and I request that it be given to me or to the person named below for whom I am authorized to make this request.
I understand that all immunizations will be reported to the California Immunization Registry (CAIR2). I understand the information in the patient's CAIR2 record will be shared with the local health department and California Department of Public Health, shall be treated as confidential medical information, and shall be used only as allowed by law. I may refuse to allow information to be further shared and can request the CAIR2 record be locked by visiting the request to lock my CAIR record web form on the CAIR website at http://www.cairweb.org.
MINOR CONSENT ONLY
I declare that I am the parent of the below-named minor child, the legal guardian of the below-named minor child, an emancipated minor at least 16 years of age, or a person with the authorizty to make healthcare decisions on behalf of the below-named minor child.
I attest I have read and understand the Vaccine Information Sheet for the seasonal influenza vaccine and understand the risks and benefits. I give consent for the below-named minor child to receive the influenza vaccine. (If you do NOT give consent, do not complete this form). I understand that by providing my voluntary consent, the below-named minor child can receive the influenza vaccine with or without a parent of guardian being physically present at the vaccination appointment.
I consent to and authorize all medically necessary treatment in the rare event that the minor patient has a reaction to the vaccine, including but not limited to itching, swelling, fainting, anaphylaxis, and other reactions.
I understand that all immunizations will be reported to the California Immunization Registry (CAIR2). I understand the information in the patient's CAIR2 record will be shared with the local health department and California Department of Public Health, shall be treated as confidential medical information, and shall be used only as allowed by law. I may refuse to allow information to be further shared and can request the CAIR2 record be locked by visiting the request to lock my CAIR record web form on the CAIR website at http://www.cairweb.org.