3012 Eastpoint Parkway, Louisville, KY 40223 | (502) 365-4545 | www.louisvillelifestylemedicine.com
Flu Vaccination Consent Form
It is recommended that anyone receiving a vaccine remain for atleast 15 minutes after to monitor for allergic reactions.
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Have you had the flu shot before?
Yes
No
Are you allergic to thimerosal, eggs, or egg products?
Yes
No
Have you ever had an allergic reaction toflu or other vaccine?
Yes
No
Is there a chance you are pregnant?
Yes
No
Are you currently sick (does not includeminor illnesses)?
Yes
No
Do you have a history of Guillain-BarreSyndrome?
Yes
No
I have answered the above questions to the best of my knowledge. I havereceived and read the information sheets for the flu vaccination I wish to receiveand have had the opportunity to ask questions. I agree to remain in the clinic forat least 15 minutes after vaccination if it is my first time being vaccinated. Ihereby consent to the administration of the flu vaccine.
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: