Flu/vaccine consent

Vaccination Consent Form

Flu/Other vaccines
Name of person receiving vaccine*

First NameLast Name
Today's Date*

MonthDayYear
Date
Date of Birth of person receiving vaccine*

MonthDayYear
Date
Has the Patient Had a Flu Shot Before?

YesNo
Screening for Vaccine Eligibility

The following questions will help us to know if you get the seasonal influenza vaccine. If you answer “NO” to all of the following questions, you can get the influenza vaccine. If you answer “YES” to one or more of the following questions, we will discuss your options for the flu shot.
Please mark YES or NO for each question.
1. Does the patient have a serious allergy to eggs or chickens?*

YesNo
2. Does the patient have any other serious allergies? Please list: *
3. Has the patient ever had a serious reaction to a previous dose of flu or other vaccine?*

YesNo
4. Has the patient ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness)?*

YesNo
5. Does the patient currently feel ill?*

YesNo
6. Has the patient had a fever in the last 24 hours?*

YesNo
Check box that correspond to your situation:*

I authorize Dr. Risa Davidson to bill my insurance via VAXCARE and verify that I have input my information into VAXCARE to the best of my ability.I do not have any private or government funded health benefit plan and/or will separately pay for my vaccination.
I understand that if my insurance is not accepted via VAXCARE then I am responsible for payment for the specific vaccination given and will pay prior to leaving. Dr. Davidson has notified me of this prior to the visit as well. Influenza injection and Flu mist is $35 and high dose Influenza for 65 years and older is $60.*

YesNo
Vaccination patient is receiving (check all that apply)*

Influenza injection (6 months-64 years of age)Influenza mist (2 years and older)Influenza injection high dose (65 years and older)Moderna COVID vaccination (booster)- not available yet
Vaccine Information Sheets

1. Inactivated Flu Vaccine Injection: https://www.immunize.org/vis/flu_inactive.pdf

2. Live Nasal Mist: https://www.immunize.org/vis/flu_live.pdf

3. All other vaccinations: https://www.cdc.gov/vaccines/hcp/vis/current-vis.html
Consent for Vaccination

I have read the most current Vaccine Information Statement published by the CDC for the seasonal influenza vaccine or other vaccine I am receiving today and understand the risks and benefits. I give consent for PRACTICE to administer the flu vaccine or other vaccine I have chosen today. I understand Dr. Risa Davidson may not be my PCP therefore any questions must be directed toward my own primary care physician.
Name of person completing form*

First NameLast Name
Signature of Patient (guardian for minors)*

Clear
Should be Empty:

Vaccination Consent Form

Screening for Vaccine Eligibility

Please mark YES or NO for each question.

Consent for Vaccination