Flu Vaccine Clinic Screening & Consent Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Primary Care Provider
*
Primary Care Provider Phone
*
Please enter a valid phone number.
Have you been immunized of the following:
*
Hepatitis A
Hepatitis B
Pneumonia
Tetanus (every 10 years)
Influenza (Flu)
How many vaccines have you received?
*
1
2
How many vaccines have you received?
*
1
2
3
Please read the list below and indicate Yes or No for the person receiving the vaccine today
Has the person ever had an allergic or severe reaction to any vaccine that required medical care?
*
Yes
No
Is this person allergic to eggs, Bakers Yeast, Streptomycin or Neomycin?
*
Yes
No
Does this person have a fever, diarrhea, or vomiting today?
*
Yes
No
Has this patient had Guillian-Barre syndrome?
*
Yes
No
Acknowledgements
*
I have read, or have had explained to me, information about the disease(s) and vaccine(s) I will be given.
I have had a chance to ask questions that were answered to my satisfaction.
I believe and understand the benefits and risks of the vaccine(s) and ask the vaccine(s) be given to me or the person named above (for whom I am authorized to make this request)
I understand that it is recommended I stay on location for 15 minutes following the injection.
Vaccine Information Sheet
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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