2026-2027 Influenza (Flu) Consent Form
Name
*
First Name
Last Name
Are you a resident of a Long Term Care facility or an employee/staff member ?
*
Resident
Staff Member
Facility Name
*
Gender
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Upload a photo of Pharmacy Insurance Card
Browse Files
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of
Pharmacy Insurance Card Name
*
We reserve the right to reject your vaccine if this section is filled out incompletely.
Pharmacy Insurance ID/Policy #
*
We reserve the right to reject your vaccine if this section is filled out incompletely.
Pharmacy BIN#
*
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance PCN#
*
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance Group #
*
We reserve the right to reject your vaccine if this section is filled out incompletely.
Social Security Number
*
This helps us obtain your correct insurance information if you provide us with the wrong card.
Allergies:
*
If no allergies type "NONE"
Do you consent to receive the 2026–2027 seasonal INFLUENZA vaccine?
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Yes, I consent
No, I decline
Any known allergies?
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Yes
No Known Allergies
Allergies:
*
List known allergies
Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers?
*
YES
NO
YES
NO
YES,I would like to receive the selected 2026–2027 seasonal INFLUENZA vaccine. My preferred vaccine is:
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Standard Dose (Under 65 years of age)
Senior Dose (Over 65 years of age)
Egg Free (Egg Allergy)
CONSENT OR DECLINATION AFFIRMATION: I have been offered the 2026–2027 seasonal INFLUENZA vaccine. I have read or had explained to me the applicable Vaccine Information Statement(s), had the opportunity to ask questions, understand the benefits and risks, and consent to the vaccine(s) selected. If I decline vaccination and a suspected or confirmed outbreak occurs within the facility, I understand I may be required to follow the facility's infection prevention and isolation procedures.
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Print Name
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