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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Year
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Phone Number
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Social Security Number
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Address
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Street Address
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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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Are you sick today?
Do you have allergies to medications, food, a vaccine component, or latex? Such as: neomycin, eggs, gelatin, MSG? Please list:
Have you ever had a serious reaction after receiving a vaccination?
Do you have long-term health problems with heart disease, lung disease, asthma, kidney disease, metabolic disease (ex: diabetes), anemia or other blood disorder?
Do you have cancer, leukemia, HIV/AIDS or any other immune system problems?
In the past 3 months have you taken medications that affect your immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease or psoriasis; or have you had radiation treatments?
Have you had a seizure, brain or other nervous system problems? Such as Guillain-Barre Syndrome or other nervous system problems?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin, or an antiviral drug?
For Women: Are you pregnant or is there a chance you could become pregnant during the next month?
Have you received any vaccinations in the past 4 weeks?
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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