• Influenza Vaccine         Consent Form

    Influenza Vaccine Consent Form

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  • 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. 

  • 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.   
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