Student Flu Vaccine Consent

Student Flu Vaccine Consent Form

For on-site school immunization clinics
Student's Name

First NameLast Name
**If student is 18 years of age or older, they must complete their own consent form. Please click here: https://form.jotform.com/232387131939058
Parent or Legal Guardian's Name

First NameLast Name
Parent or Legal Guardian's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent or Legal Guardian's Email
example@example.com
Student's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student's Age
Student's Gender
Student's Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Student's Doctor's Name (Last, First)
Doctor's City
School Name
Homeroom Teacher's Name
Student's Grade
The following questions will help us to know if your child can get the seasonal influenza vaccine. If you answer “NO” to all four of the following questions, your child can probably get the influenza vaccine. If you answer “YES” to one or more of the following four questions, your child may be able to get the seasonal influenza vaccine, but we will contact you to discuss your options.
Does your child have a serious allergy to eggs?
Does your child have any other serious allergies?
Please list serious allergies:
Has your child ever had a serious reaction to a previous dose of flu vaccine?
Has your child ever had Guillain-Barre Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine?
I have read or had explained to me the Vaccine Information Statement for the seasonal influenza vaccine and understand the risks and benefits.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hale Center Clinical Pharmacy is only able to offer influenza vaccine to student's with health care coverage. Please provide the following information from your child's insurance or Medicaid.
Cardholder's Name
Insurance Company Name
Child's Insurance ID Number
Rx BIN Number
Rx PCN Number
Rx Group Number
Should be Empty:

Student Flu Vaccine Consent Form