Patient Request and Consent for Flu Vaccination 2026

Patient Request & Consent for Vaccination

Completing this form ensures Fair Oaks Estates has clear, timely direction from the responsible party about the resident’s participation in our on‑site flu vaccination clinic administered by Yolo Pharmacy.

Your response, whether granting permission or declining at this time, helps us coordinate care safely, share essential information with the vaccinating pharmacist and document your decision in the resident’s record. Even if no immunization is requested now, recording that choice avoids scheduling errors, reduces unnecessary outreach, and confirms your preferences for this flu season.

*https://www.cdc.gov/vaccines/hcp/vis/vis-dates.html

Do you give permission for your resident to receive the influenza (flu) vaccine at Fair Oaks Estates during the on-site flu clinic administered by Yolo Pharmacy?

Resident Name

First NameLast Name

Resident's Responsible Party Name

First NameLast Name

Phone Number

Resident's Responsible Party PhoneFormat: (000) 000-0000.

Email

Resident's Responsible Party Email

Residents Room Number

Date of Birth

Date

Age

Primary Care Doctor

Vaccine Requested

Allergies

List all known allergies, separated by commas

Is Resident allergic to eggs, latex, or any vaccine component, such as gelatin or neomycin?

Has Resident ever had a serious reaction after receiving a vaccination?

Any history of Guillain-Barre’ Syndrome, seizure disorder, or other neurological condition?

Has Resident had a POSITIVE COVID test in the past 14 days?

Please identify any vaccine(s) resident has already received:

Please check any chronic or long-term health conditions resident may have:

Has Resident received any vaccines in the past 4 weeks?

Does Resident have cancer, leukemia, AIDS, or any other immune system problem?

Has Resident taken any steroids, anti-cancer drugs, antivirals, immunosuppressive medications, or have you ever had radiation treatments in the last 3 months?

In the past year, has resident received a transfusion of blood or blood products, or been given immune (gamma) globin?

I {patientGuardian} hereby give my consent to Yolo Pharmacy to administer the vaccine(s) I have requested on this form. I understand the benefits and risks of receiving this vaccine(s). I acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration. I understand that my immunization information will be shared with my prescriber and local immunization registry, but that I have rights pertaining to the use of this data, including the right to prevent sharing with other registry users by completing and submitting a “Decline to Share” form to my local registry Help Desk. For more information, California patients should visit the CAIR website (http://cairweb.org/cair-forms/).

Pharmacy as per ACIP recommendations and in conjunction with our vaccination protocol. This data will be uploaded into the vaccination state registry within 24 hours after clinic.

Date

File Upload

Resident's Responsible Party Signature