Influenza Immunization Consent Form

Patient Name *

First Name Last Name

Date of Birth *

Date

The MIIS (Massachusetts Immunization Information System) is an electronic medical record for immunizations. The goal of the MIIS is to give health care providers and families a tool to help ensure that all individuals are immunized based on the latest recommendations. Because of this system, we no longer fax providers records of immunizations.

For patients (both children and adults) to be vaccinated:

The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable influenza vaccination today. If you answer “yes” to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked.

If a question is not clear, please ask your healthcare provider to explain it.

Please read the following VIS (Vaccine Information Statement)

Flu Vaccine: What You Need to Know

1. Did you read the Vaccine Information Statement (above)? *

Yes No Don't know

2. Is the person to be vaccinated sick today? *

Yes No Don't know

3. Does the person to be vaccinated have an allergy to a component of the vaccine? *

Yes No Don't know

4. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? *

Yes No Don't know

5. Has the person ever had a serious reaction after a vaccination? *

Yes No Don't know

6. Has the person to be vaccinated ever had Guillain-Barré syndrome? *

Yes No Don't know

Form completed by *

First Name Last Name

Date *

Date

Signature *

Clear

Form Reviewed By/ Date Reviewed:

Clear

Influenza Screening Checklist

Please read the following VIS (Vaccine Information Statement)