Influenza Immunization Consent Form

**** Please do not fill this form out until it is the day you want to come for the vaccine, or the information will no longer be accurate ****

** If this is your first time receiving a vaccine from us, please also fill out the HIPAA Card**

Patient Name*

First NameLast Name

Date of Birth*

Date

In which arm would you like to receive the vaccine?

Left ArmRight Arm

Select the flu vaccine you would like to receive

High Dose (age 65+)Regular Dose (under age 65)

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)?*

YesNoDon't know

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

YesNoDon't know

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

YesNoDon't know

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

YesNoDon't know

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

YesNoDon't knowOther

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

YesNoDon't know

Form completed by*

First NameLast Name

Date*

Date

Signature*

Form Reviewed By/ Date Reviewed:

Influenza Screening Checklist

Please read the following VIS (Vaccine Information Statement)