2026 Offsite Flu Shot Consent Form

School/Facility Name (no abbreviations or shorthand)
Name

First NameLast Name
Middle Initial
Mailing Address
Address
City, State, Zip
City, State, Zip Code
County
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Age
Gender
Race
Ethnicity
Mothers Maiden Name
Required for SC Immunization Registry
Emergency Contact Information:
Name
Relation
Phone Number
Format: (000) 000-0000.
Primary Physician Information:
Name
Physician's Name
Phone Number
Physician's Phone NumberFormat: (000) 000-0000.
City & State
Physician's City & State
Insurance Information
Cardholder Name
Rx BIN
Rx PCN
Cardholder ID
Rx Grp
Medicare Number
Please Answer the Following Questions:
Have you ever fainted or felt dizzy after receiving a vaccine?
Have you ever had a reaction after receiving a vaccine?
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurological or neuromuscular disease, liver disease (e.g., diabetes), or anemia or another blood disorder?
Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs?
Do you have allergies to latex, medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)
Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain-Barré syndrome or other nervous system problems?
For woman: Are you pregnant or considering becoming pregnant in the next month?
Have you received ANY vaccinations in the past 4 weeks?
Has it been at least 2 months since your last COVID-19 vaccine?
Have you tested positive for COVID-19 in the past 3 months?
I have read, or had explained to me, the Vaccine Information Statement dated 8/06/21 for INACTIVATED INFLUENZA vaccine. I understand the risks and benefits. I have been provided an opportunity to ask questions and they were answered to my satisfaction. I hereby give my consent to receive the vaccine listed in the VIS and to communicate the administration of the vaccine to my primary care practitioner. I have read the posted copy of the Patient's Privacy Policy (a copy is available upon request The VIS is located at https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html
Signature or person to receive vaccine or their guardian
Should be Empty:

Insurance Information

Please Answer the Following Questions: