Flu Vaccine 65+ 2024-25 Consent and Questionnaire

26A Picotte Drive

Albany, NY 12208

(518)435-2315

Flu Vaccine Administration Form

Please read the Vaccine Information Sheet by clicking here.
Date*

MonthDayYear
Date
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Age*
Phone*
Email
example@example.com
Gender (M/F)*
Home address*
City*
State*
Zip*
Insurance Plan Name*
ID#
BIN
PCN
GROUP #
If you have Medicare (Red, White & Blue Card) please enter Medicare ID or last four of SSN below. *
Primary Care Provider/Doctor Name
Primary Doctor's Phone Number
Please answer the following questions. They will help us determine your eligibility to receive a vaccination today.
Do you currently feel sick?*

YesNoUnsure
Have you been sick in the last 2 weeks?*

YesNoUnsure
Do you currently have a fever? *

YesNoUnsure
Do you have any health conditions (e.g diabetes, heart disease, asthma, etc?)*

Yes (Please List Below)NoUnsure
Health Condition from above question
Have you received the flu vaccine before?*

YesNoUnsure
Have you had a reaction to the vaccine before?*

Yes (Please list Below)NoUnsure
Reaction(s) to vaccine(s), please list
Do you have allergies to medications or food?*

Yes (Please list below)NoUnsure
If yes, please list:
Are you allergic to Eggs or Dairy?*

YesNoUnsure
Are you allergic to thimerosal?*

YesNoUnsure
Are you currently pregnant?*

YesNoUnsure
Are you a health care worker?*

YesNoUnsure
Have you ever had Guillain-Barre Syndrome?*

YesNoUnsure
Do you have a blood-clotting disorder? *

YesNoUnsure
Are you taking any blood-thinning medications?*

Yes (List Below)NoUnsure
If Yes, Please List
Please read carefully and sign below.

I, the undersigned, have read or had explained to me the vaccine information sheet (VIS). I understand that it is not possible to predict all side effects or complications associated with receiving vaccination. I understand the risks and benefits associated with the influenza vaccine and have had any questions satisfactorily answered. I volunarily request that the vaccine be given to me or for the aforemented person for whom I am authorized to make this request.
Appointment*
Signature*

Clear
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
TYPING IN MY NAME ACTS AS A DIGITAL SIGNATURE FOR CERTIFYING THAT I REVIEWED THE VIS LITERATURE.*
To be completed by healthcare provider only:
Manufacturer
Lot #
Expiration Date

MonthDayYear
Date
Route
Site
Administered By
Date Given
Should be Empty: