Flu Vaccine Consent Form
This form is designed to gather important health information and obtain your consent for receiving the influenza (flu) vaccine. Please complete all sections accurately to ensure safe and effective vaccination. If you have any questions or concerns, consult your healthcare provider before signing.
Appointment
*
Vaccine Recipient Name
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First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Apt
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of birth
*
-
Month
-
Day
Year
Date
Vaccine Screening Question
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Rows
Yes
No
1. Are you feeling sick today (e.g., fever, cold, or other illness)?
2. Do you have any allergies to medications, food, or vaccines (especially eggs, latex, or thimerosal)?
3. Have you ever had a serious reaction to a flu vaccine in the past?
4. Have you received any other vaccines in the past 4 weeks (e.g., COVID-19, pneumonia, shingles)?
5. Are you currently taking any medications that weaken your immune system (e.g., steroids, chemotherapy)?
6. Do you have a weakened immune system due to illness or medical treatment (e.g., cancer, HIV, organ transplant)
7. Do you have any chronic medical conditions (e.g., asthma, diabetes, heart disease, lung disease)?
8. Do you have any chronic medical conditions (e.g., asthma, diabetes, heart disease, lung disease)?
9. Are you pregnant, breastfeeding, or planning to become pregnant in the next month?
10. Do you have a history of severe allergic reactions (e.g., anaphylaxis) to any vaccine or injection?
Which arm would you like to get the injection on?
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Left Arm
Right Arm
Vaccination Consent (check each box below after reading and prior to signing the form)
*
Rows
Check the box
Purpose:
The flu vaccine is intended to reduce the likelihood of contracting influenza, and while it is highly effective, no vaccine is guaranteed to provide complete protection.
Benefits:
Vaccination is an important tool in preventing serious illness, hospitalization, and death caused by the influenza virus.
Risks:
I am aware that, as with any medical procedure, there are potential risks, including but not limited to mild side effects (such as soreness, redness, or swelling at the injection site, fever, or fatigue), and in rare cases, severe allergic reactions or complications like Guillain-Barré Syndrome.
Alternatives:
I understand that I have the right to refuse vaccination and that alternative preventive measures, such as wearing masks, hand washing, and avoiding contact with infected individuals, can reduce the risk of contracting the flu.
Disclosure of Medical Information:
I have provided accurate and complete information about my health history, including any allergies, medical conditions, and medications that may affect the administration of the vaccine.
Voluntary Participation:
I understand that receiving the flu vaccine is voluntary and that I can decline vaccination at any time without losing access to other health services or benefits.
Pregnancy and Immunocompromised Conditions:
(If applicable) I have disclosed if I am pregnant, breastfeeding, or have any conditions that compromise my immune system.
The vaccine is available to anyone no matter if insured or uninsured. Please checkonly one of the following.
*
If INSURED, check this box attesting to bringing in your prescription and medicalinsurance cards for your vaccine appointment. By selecting this, you are alsoauthorizing the pharmacy to bill your insurance on your behalf for the immunization –understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the the following information istrue and accurate: I do not have any insurance, including but not limited to, Medicare,Medicaid, or any other private or government-funded benefit plan.
Please Upload Insurance Card
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For uninsured patients, please select at least one of the following that you will bringwith you to your appointment.
*
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Uninsured Document
*
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Signature of Person to Receive Vaccine (or Signature of Parent/Guardian if Patient is < 18 years old):
*
Date Signed
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-
Month
-
Day
Year
Date
Submit
Should be Empty: