Influenza Consent

Influenza(flu) Vaccination Consent

Please take a moment to review and consent to you receiving the flu vaccine for the flu season.
At this time we are unable to vaccinate anyone under the age of 7.

Current Health Questionnaire
HQ01 - Is the recipient feeling sick today?
HQ02- Has the recipient had an allergic reaction to a vaccine?
HQ03 - Is the recipient allergic to thimerosal?
HQ04 - Is the recipient allergic to Neomycin or Latex?
HQ05 - Does the recipient have an allergic reaction to eggs, chicken, or chicken feathers?
HQ06 - Does the recipient have a bleeding disorder?
HQ07 - Is the recipient pregnant?
HQ07 - Is the recipient pregnant?
HQ07 - Is the recipient pregnant?
HQ08 - Is the recipient taking any medication that may affect blood clotting?
HQ09 - Has the recipient been diagnosed with Guillain-Barre Syndrome?
HQ10 - Has the recipient been diagnosed with Oculorespiratory Syndrome?
HQ11 - Does the recipient have any Immunological deficiencies? (i.e., HIV/AIDS, Diabetes...)
HQ12 - Has the recipient received a live vaccination in the past 30 days? (i.e.,MMR, Rotarix)?

Consent for vaccination
Consent to Vaccinate

I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice before coming here today. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine. I consent to receiving the influenza vaccine.

We are unable to vaccinate anyone under the age of 7. Thank you for your understanding.

Pharmacy Use Only:
Highdose
Lowdose
Vaccination
Influenza Vaccine Administered:

FlulavalFluad (Age 65 and older)Flucelax (Egg Free)
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Vaccine Administered on

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Administered by Name and Title:
Administered by Signature

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Vaccine Name

Influenza(flu) Vaccination Consent