2025 Flu Vaccination Online Acknowledgement

Patient Name
Which NHC Location? *
Do you want the above referenced patient to receive the flu vaccination?

YesNo
Has the above referenced patient ever had a severe reaction to a previous vaccination including neurological (nerve or muscle) complications to your knowledge?

YesNo
Does the above referenced patient have an allergy to eggs?*

YesNo
Please review the CDC Influenza information attached or at the CDC website link at: https://www.cdc.gov/flu/prevent/keyfacts.htm
Date

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Date
Signature

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