Vaccination Consent Form For All Vaccines
Patient Full Name
*
First Name and Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Medicare or Social Security Number (if available):
1. Is the person to be vaccinated sick today?
*
Yes
No
2. Does the person to be vaccinated have any allergies to medications, food, a vaccine component, or latex?
*
Yes
No
3. Has the person to be vaccinated ever had a serious reaction after receiving a vaccination in the past?
*
Yes
No
4. Does the person have any long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
*
Yes
No
5. Does the person have cancer, leukemia, AIDS, or any other immune system problem?
*
Yes
No
6. Does the person take cortisone, prednisone, other steroids, or anti-cancer drugs, or have you had radiation treatments?
*
Yes
No
7. Has the person had a seizure or a brain or other nervous system problem?
*
Yes
No
8. During the past year, has the person received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
*
Yes
No
9. For women: Is the person pregnant or is there a chance she could become pregnant during the next month?
Yes
No
10. Has the person received any vaccinations in the past 4 weeks?
*
Yes
No
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
Take A Picture of Insurance Card (Front Side)
Take A Picture of Insurance Card (Back Side)
Administration Site
Left Arm
Right Arm
Dosage
0.5ml
2.5ml
LAIV
Submit
Should be Empty: