Influenza Vaccine Consent

Name*

First NameLast Name

Social Security Number (SSN)

Optional

Date of Birth (mm/dd/yyyy)*

Cell Phone*

Please enter a valid phone number.

May we leave a voicemail?

YesNoN/A

Alt. Phone*

Please enter a valid phone number.

May we leave a voicemail?

YesNoN/A

Email Address

example@example.com

1) Have you had a flu shot before?*

YesNo

2) Do you feel sick today or have a fever?*

YesNo

3) Have you ever had a SEVERE reaction to the flu shot?*

YesNo

If yes, please explain:

4) Have you ever had Guillian-Barre Syndrome? This affects the central nervous system as an ascending/upwardly moving paralysis*

YesNo

5) Are you able to eat lightly cooked eggs (ex.scrambled) without an allergic reaction?*

YesNo

6) Have you ever had a reaction to latex?*

YesNo

7) Do you have a blood clotting disorder and/or take anticoagulant medication which may result in increased bruising?*

YesNo

I have read or have had explained to me the information on this form about the influenza vaccine. I have been provided with the Influenza Vaccine Information Statement and had a chance to ask questions, which were answered to my satisfaction. I understand the benefits and risks of the vaccine and I request that the vaccine be given to me or to the person named above, for whom I am authorized to make this request.

Signature (Signature of person to receive vaccine or Legally Empowered Representative)*

Date*

F1012 / APPROVED FOR USE

INFLUENZA VACCINE CONSENT FORM

Please fill out any/all contact methods.