Influenza Vaccination Consent Form
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Address
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Patient Social Security Number or Medicare Number
Is the person to be vaccinated sick today?
*
Yes
No
Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine?
*
Yes
No
Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
*
Yes
No
Has the person to be vaccinated ever had Guillian-Barre syndrome?
*
Yes
No
Signature
*
Date
*
/
Month
/
Day
Year
Date
To be completed by Pharmacist
Administration Date
*
/
Month
/
Day
Year
Date
Administration Site
*
Left Arm
Right Arm
Dosage
0.5ml
2.5ml
LAIV
Type option 4
Vaccine Name
*
Please Select
Fluad
Flucelvax
Manufacturer & Lot Number
*
VIS Date
*
-
Month
-
Day
Year
Date
Pharmacist's Signature
*
Date
*
/
Month
/
Day
Year
Date
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