FLU SHOT QUESTIONNAIRE

Influenza Vaccine Consent Form

1.I received a copy of the Vaccine Information Statement (VIS) QR code also provided below 2.I understand why it is important to get vaccinated for the flu. 3.I understand and know the risks of a vaccine reaction and will remain at this location for 15 minutes after receiving the vaccination. 4.I understand and know what to do if the child or myself experiences a reaction. 5.I have had the opportunity to ask questions about any concerns I have related to the prevention of influenza and how the vaccine is administered..I am 18 years or older who can legally consent for the child (age 6-17) named below to get the vaccine or myself. I understand this is voluntary and give my permission to receive this vaccine. I have read the above information and have requested that the vaccine be given to the person named below for whom I am authorized to sign or myself.

Patient Information (Please Print)

Name*

First NameMiddle InitialLast Name

DOB mm/dd/yy*

Sex

MaleFemale

Street Address*

City*

Zip*

Name of Parent/Guardian*

Phone #*

Signer's Relationship to Patient*

selfparentguardianother

Signature of parent/ guardian/ self*

Date

Immunization screening Checklist

Patient Name*

Date of Birth*

Date

Insurance ID

For patients (both children and adults) to be vaccinated: The following questions will help us determine if there is any reason, we should not give you or your child inactivated injectable influenza vaccination today. If you answer "yes" to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

Is the person to be vaccinated sick today?*

yesnodon't know

Does the person to be vaccinated have an allergy to a component of the vaccine?*

yesnodon't know

Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?*

yesnodont know

Has the person to be vaccinated ever had Guillain-Barre Syndrome?*

yesnodont know

Signature: (Form completed by) *

date*

Date

Form reviewed by

PLEASE UPLOAD AN IMAGE OF YOUR INSURANCE CARD IF YOU HAVE IT, FRONT & BACK 65+ PLEASE UPLOAD YOUR RED WHITE AND BLUE CARD. THANK YOU!

QR CODE VIS SHEET