Flu/Covid Vaccine Consent Form

Adult Flu/Covid Vaccine Consent Form
Name

First NameLast Name
Date Today

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Age
Gender
Mother's Maiden Name
Last 4 Digits of Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of your Doctor

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Vaccine to be Administered
Are you feeling sick today?
Do you have any health conditions, such as heart disease, diabetes or asthma?
Please indicate your health conditions below
Do you have allergic reaction to medications, food, or any ingredients or materials used with vaccine (i.e. aluminum, eggs, bovine protein, gelatin, neomycin, gentamicin, latex,polymyxin, thimerosal, preservatives, etc.)?
Please indicate below
Have you ever had a serious reaction after receiving a vaccination, such fainting or feeling dizzy?
Have you ever had a seizures, brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?
Have you received any vaccinations or skin tests in the past 2 weeks?
Please list below
Are you currently on home infusions, weekly injections, anticancer drugs or radiation treatments?
Are you currently taking high-dose steroid therapy for longer than 2 weeks?
Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in the past year?
Are you pregnant or planning to be pregnant in the next 30 days
Let us know when you're coming!
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Adult Flu/Covid Vaccine Consent Form