Flu vaccine consent

Influenza Vaccine Consent Form
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Have You Had a Flu Shot Before?

Yes No
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. Do you have a serious allergy to eggs or chickens? *

Yes No
2. Do you have any other serious allergies? Please list: *
3. Have you ever had a serious reaction to a previous dose of flu vaccine? *

Yes No
4. Have you ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness)? *

Yes No
5. Do you currently feel ill? *

Yes No
Check boxes 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 (check box if true) If uninsured please, please select option below
If uninsured, please verify that the below information is true and accurate.

I do not have any insurance, including but not limited to Medicare, Medicaid, or any other private or government funded health benefit plan.
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
Consent for Vaccination

I have read the 2022 Vaccine Information Statement for the seasonal influenza vaccine and understand the risks and benefits. I give consent for PRACTICE to administer the flu vaccine.
Signature of Patient (guardian for minors) *

Clear
Should be Empty:

Influenza Vaccine Consent Form

Screening for Vaccine Eligibility

Please mark YES or NO for each question.

Consent for Vaccination