Flu Vaccine Consent Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Date of Birth

Date

Date Today

Date

Gender

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of your Doctor

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Vaccine to be Administered

MMR IIVaxchoraOther

Are you feeling sick today?

YesNo

Do you have any health conditions, such as heart disease, diabetes or asthma?

YesNo

Please indicate your health conditions below

Do you have allergic reaction to medications, food, or any ingredients or materials used with vaccine (i.e. aluminum, eggs, bovine protein, gelatin, neomycin, gentamicin, latex,polymyxin, thimerosal, preservatives, etc.)?

YesNo

Please indicate below

Have you ever had a serious reaction after receiving a vaccination, such fainting or feeling dizzy?

YesNo

Have you ever had a seizures, brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?

YesNo

Have you received any vaccinations or skin tests in the past 4-8 weeks?

YesNo

Please list below

Are you currently on home infusions, weekly injections, anticancer drugs or radiation treatments?

YesNo

Are you currently taking high-dose steroid therapy for longer than 2 weeks?

YesNo

Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in the Yes No Don’t knowpast year?

YesNo

Have you had yellow fever?

YesNo

Do you have a history of thymus disease or had your thymus removed?

YesNo

Do you have a history of thrombocytopenia or thrombocytopenia purpura?

YesNo

Have you consumed any food or drink in the last hour?

YesNo

Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days?

YesNo

Are you pregnant or planning to be pregnant in the next 30 days

YesNo

Has your child had wheezing or asthma in the past 12 months?

YesNo

Have you had a shingles vaccination or been diagnosed with shingles in the last 12 months?

YesNo

Have you ever had a pneumococcal vaccination?

YesNo

I hereby give my consent to the administering of the flu vaccine as specified to the choice above. I acknowledge the risks and benefits in administering of the vaccine. I likewise understand that such risks of having side effects or complications associated with the receiving of the vaccine cannot be predicted.

I have been advised to stay in the facility for at least 15 minutes after the vaccine has been given to me for observation.

I hereby release and hold harmless the facility, its staff, agents, employees, successors, affiliates, subsidiaries, directors, and officers from any and all liabilities or claims whether known or unknown arising from, or in connection with the administration of the vaccine listed above.

I authorize the disclosure of my information for the purpose of necessary processing, recording of my information relevant to the administering of the vaccine including claims for costs and fees.

I agree to be responsible for any financial cost-sharing amounts, including copays, coinsurance, and other deductibles including those which are not covered by my insurance benefits.

Age of Consent

I hereby declare that I am of legal age and I give my consent with full knowledge and responsibility to the risks and benefits of the vaccine. I have had the opportunity to ask questions and which answers were given to me to my satisfaction.I am the legal representative of the above-named patient. The patient is of legal age and I am executing this document on his/her behalf. He/she have had the opportunity to ask questions and which the answers were provided to him/her to his/her satisfaction.I am the legal guardian of the above-named patient. I am executing this document on his/her behalf with my full consent and authority. I have had the opportunity to ask questions and by which answers were given to me to my satsifaction.

Name

First NameLast Name

Date

Signature