Flu Vaccine Requirement Form

Flu Vaccine Requirement Form
Receiving a vaccine helps protect individuals from being infected with diseases. However, as much as it shows benefits, it may have adverse effects on the human body. Allergic reactions of the body may appear in a form of itching, swelling, redness, or tenderness. Fever, muscle pains, or malaise may also happen. In case of any severe reaction such as fever, difficulty in breathing, increased heartbeat, dizziness, we recommend to please see your doctor.
Individuals are required to be administered for Flu Vaccine. Please fill out the information below for information about you or your child with regard to receiving a flu vaccination.
Name of Patient
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Vaccination Status
Will receive flu vaccineWill not receive flu vaccine
Reason for not receiving vaccine
Please indicate the reason such as religion, has already received one, etc.
I have received educational information with regard to the need for vaccination. I have had the opportunity to ask questions and by which I have received a satisfactory answer.
I hereby declare that the information I have provided above is true and correct to the best of my knowledge.
Consent*
I hereby declare that I am at least 18-years of age. I am giving my consent following the information I have provided above to be true and correct to the best of my knowledge.I am the legal guardian/representative and I am signing this form for the above-named individual. I hereby declare that I am disclosing the information and giving my consent as provided above to the best of my knowledge.
Signature
Clear
Date
MonthDayYear
Date
Name of Legal Guardian/Representative
First NameLast Name
Signature of Legal Guardian/Representative
Clear
Date Signed by Legal Guardian/Representative
MonthDayYear
Date
Should be Empty: