Adult Flu/Covid Vaccine Consent Form
Name
First Name
Last Name
Date Today
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Please Select
Male
Female
Mother's Maiden Name
Last 4 Digits of Social Security Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of your Doctor
First Name
Last Name
Doctor's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Vaccine to be Administered
Influenza
Influenza High Dose - Age 65 and over
Covid-19
Covid-19 & Influenza
Covid-19 & Influenza HD -Age 65 and over
Are you feeling sick today?
Yes
No
Do you have any health conditions, such as heart disease, diabetes or asthma?
Yes
No
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.)?
Yes
No
Please indicate below
Have you ever had a serious reaction after receiving a vaccination, such fainting or feeling dizzy?
Yes
No
Have you ever had a seizures, brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?
Yes
No
Have you received any vaccinations or skin tests in the past 2 weeks?
Yes
No
Please list below
Are you currently on home infusions, weekly injections, anticancer drugs or radiation treatments?
Yes
No
Are you currently taking high-dose steroid therapy for longer than 2 weeks?
Yes
No
Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in the past year?
Yes
No
Are you pregnant or planning to be pregnant in the next 30 days
Yes
No
Let us know when you're coming!
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