Influenza Vaccine Consent Form
Patient Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
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Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Hawaii
Idaho
Illinois
Indiana
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Gender
Female
Male
Ethnicity:
Hispanic or Latino
Non-Hispanic/Latino
Unknown
Prefer not to answer
Other
Race
African American
American Indian
Asian
Caucasian
Native Hawaiian/ Other Pacific Islander
Prefer not to answer
Other
Commercial Insurance
*
BIN Number
PCN Number
Group Number
ID Number
Picture of insurance card
Browse Files
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Cancel
of
Insured Patients
I authorize the pharmacy to bill my insurance on my behalf for the immunization.
Screening for Immunization
Does the person to be vaccinated have a fever or illness today?
Yes
No
Does the person to be vaccinated have an allergy to eggs, latex, or to a component of the vaccine?
Yes
No
Has the person to be vaccinated ever had a serious reaction to this vaccine in the past?
Yes
No
Has the person to be vaccinated ever had Guillain-Barre syndrome less than 6 weeks after vaccination, uncontrolled seizures or any unstable neurological disorder?
Yes
No
Has the person to be vaccinated received any vaccines in the past 30 days?
Yes
No
Is the person to be vaccinated 6 years of age or older?
Yes
No
Is the person to be vaccinated currently pregnant, breastfeeding, or planning to become pregnant in the next 30 days?
Yes
No
Consent for Immunization
I, undersigned, agree with the followings:
I certify that the information above is correct and accurate to the best of my knowledge.
I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving.
All my questions concerning the vaccine have been answered to my satisfaction.
I understand the benefits and risks of receiving the vaccine and request that it be given to me.
I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.
Date
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Month
-
Day
Year
Date
Signature
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