2025-2026 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
*
Sex
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
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
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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"
Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers?
*
YES
NO
Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness?
*
YES
NO
Is the person receiving the vaccine allergic to Neomycin, Thimerosal (Preservative found in contact lens solution), any vaccine ingredient, or latex?
*
YES
NO
Is the person being administered the regular or senior-dose flu vaccine?
*
Regular Dose (Under 65 years of age)
Senior Dose (Over 65 years of age)
I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine.
*
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