Flu Vaccine 2025-26 Consent and Questionnaire

26A Picotte Drive

Albany, NY 12208

(518)435-2315

Flu Vaccine Administration Form

Please read the Vaccine Information Sheet by clicking here.

Date*

Date

First Name*

Last Name*

Date of Birth*

Date

Age*

Gender (M/F)*

Race*

Ethnicity*

Phone*

Email

example@example.com

Home address*

City*

State*

Zip*

Insurance Plan Name*

ID#

BIN

PCN

GROUP #

If you have Medicare (Red, White & Blue Card) please enter Medicare ID or last four of SSN below.

Primary Care Provider/Doctor Name

Primary Doctor's Phone Number

Please answer the following questions. They will help us determine your eligibility to receive a vaccination today.

Do you currently feel sick?*

YesNoUnsure

Have you been sick in the last 2 weeks?*

YesNoUnsure

Do you currently have a fever? *

YesNoUnsure

Do you have any health conditions (e.g diabetes, heart disease, asthma, etc?)*

Yes (Please List Below)NoUnsure

Health Condition from above question

Have you received the flu vaccine before?*

YesNoUnsure

Have you had a reaction to the vaccine before?*

Yes (Please list Below)NoUnsure

Reaction(s) to vaccine(s), please list

Do you have allergies to medications or food?*

Yes (Please list below)NoUnsure

If yes, please list:

Are you allergic to Eggs or Dairy?*

YesNoUnsure

Are you allergic to thimerosal?*

YesNoUnsure

Are you currently pregnant?*

YesNoUnsure

Are you a health care worker?*

YesNoUnsure

Have you ever had Guillain-Barre Syndrome?*

YesNoUnsure

Do you have a blood-clotting disorder? *

YesNoUnsure

Are you taking any blood-thinning medications?*

Yes (List Below)NoUnsure

If Yes, Please List

Please read carefully and sign below.

I, the undersigned, have read or had explained to me the vaccine information sheet (VIS). I understand that it is not possible to predict all side effects or complications associated with receiving vaccination I understand the risks and benefits associated with the vaccine and have had any questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the aforementioned person for whom I am authorized to make this request. I understand that my vaccination will be submitted NYSIIS (New York State Immunization Information System) unless otherwise stated.
I acknowledge that a pharmacist or certified pharmacy intern under a pharmacists supervision will be administering the vaccine.

Appointment*

Signature*

Date*

Date

Hour MinutesAM/PM Option

TYPING IN MY NAME ACTS AS A DIGITAL SIGNATURE FOR CERTIFYING THAT I REVIEWED THE VIS LITERATURE.*

To be completed by healthcare provider only:

Manufacturer

Lot #

Expiration Date

Date

Route

Site

Administered By

Date Given