Flu Shot Consent Form

Flu Shot Consent Form

Please complete this form to provide consent and answer screening questions for flu vaccination.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address

Street Address

CityState / ProvincePostal / Zip Code
Is the patient a minor (under 18 years old)?
Parent/Guardian Name (if patient is a minor)

First NameLast Name
Relationship to Patient (if patient is a minor)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
HAVE YOU RECEIVED THE FLU VACCINE BEFORE?
DID YOU HAVE ANY PROBLEMS WITH PREVIOUS FLU SHOTS?
DO YOU HAVE ANY ALLERGIES TO EGGS OR THIMERSOL PRESERVATIVE?
ARE YOU ILL TODAY?
DO YOU HAVE A HISTORY OF GUILLAIN-BARRE SYNDROME?
Signature (Patient or Parent/Guardian)
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Company Name
Member/Subscriber ID
Group Number
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
No insurance / self-pay
Insurance Card

Upload a clear image or PDF of the insurance card.
Cancelof
Should be Empty: