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.
Parent or Legal Guardian's Email
example@example.com
Student's Date of Birth*

MonthDayYear
Date
Student's Age*
Student's Gender*

MaleFemale
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?*

YesNo
Does your child have any other serious allergies?*

YesNo
Please list serious allergies:
Has your child ever had a serious reaction to a previous dose of flu vaccine?*

YesNo
Has your child ever had Guillain-Barre Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine?*

YesNo
I have read or had explained to me the Vaccine Information Statement for the seasonal influenza vaccine and understand the risks and benefits.*

I GIVE CONSENT to the Hale Center Clinical Pharmacy and its staff for my child named at the top of this form to be vaccinatedwith this vaccine.
Signature*

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Date*

MonthDayYear
Date
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