Influenza Informed Consent Form
2025-2026
Place of Employment:
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Today's Date
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Month
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Day
Year
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Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Social Security Number
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance
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Insurance Company
Member ID
Received Influenza Vaccination at Another Facility
I understand that I am declining the flu vaccine provided by Nor-Lea Hospital District because I have received the vaccination for this flu season elsewhere. Documentation is required.
Name of facility/clinic or physician's office where I received the flu vaccine:
Contraindication (see below) the influenza vaccine should not be taken by certain individuals. Please check any that apply.
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Have you ever experienced allergic reaction to chicken eggs, chicken feathers or chicken dander?
Have you ever had an allergic reaction to a flu vaccine?
Have you ever been allergic to Thimerosal, a mercery derivative?
Are you presently having symptoms of acute fever?
Are you now experiencing any acute and/or changing neurological disorders such as seizures?
Do you have a history of Guillain-Barre Syndrome?
Do you have any sensitivity/allergies to dry natural latex rubber?
I have read the contraindications and DO NOT have any.
If you have answered yes to any of the contraindications, the vaccine will not be administered until you receive a physician's approval.
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