Flu Consent 2024-2025

ATLANTA PEDIATRIC PARTNERS
2024 - 2025 Flu Vaccination Consent Form

(Please fill out one information sheet per child)
Patients Name
Date of Birth

MonthDayYear
Date
Has this child been seen by one of our Providers before? (If not, Please schedule a well child check wirh one of our providers within two weeks of receiving flu vaccine.)

YesNo
For child 6 months to 8 years, have they received 2 or more doses of influenza since 2016? (If not and less than 9 years old, it is recommended to get two doses of the flu vaccine this year at least 4 weeks apart.)

YesNo
Has the patient had a fever within the last 24 hours? (If yes we recommend the vaccine to a different date)

YesNo
Is the patient severely allergic to eggs? (If yes, please call the office 404.699.1339 and speak with a triage nurse to discuss your options.)

YesNo
Is the patient severely allergic to gelatin? (If yes, please call the office 404.699.1339 and speak with a triage nurse to discuss your options.)

YesNo
Has your child ever has Guillain-Barre Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine?

YesNo
By my signature below, I acknowledge access to the 2024-2025 Influenza Vaccine fact sheet code (presented below ). I understand the benefits and risks of the vaccine and I am authorizing a qualified member of Arlanta Pediatric Partners, P.C staff to administer the Influenza Vaccine according to the guidelines set by the Center for Diusease Control and Prevention.
Patient Signature
Date

MonthDayYear
Date
Relationship to Patient
(If patient is under the age of 18 the signature of a parent or legal guardian must be obtained)
Should be Empty:

ATLANTA PEDIATRIC PARTNERS