Flue vaccine consent

Flue Vaccination Consent Form

Please fill out the form to provide your consent for vaccination.
Full Name of Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I, the undersigned have read or had explained to me the vaccine information sheet (VIS). I understand the risks and benefits associated with the Flue vaccine and have had any questions satisfactorily answered. I voluntary request the vaccine be given to me or for the forementioned person for whom I am authorized to make this request.
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Are you currently ill or do you have a fever?*
Have you had a reaction to any vaccine before?*
Do you have any history of seizures or any other neurological disorder?*
Is the person receiving vaccine pregnant?
Have you ever had Gullain-Barre Syndrome?*
Signature*

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Following Section for Official USE only
Date Given*

MonthDayYear
Date
Expiry Date*

MonthDayYear
Date
Route (s/c or IM)
Manufacture and lot number*
Site (Rt DT, Lt DT)*
Administered by*
Should be Empty:

Flue Vaccination Consent Form