Staff Flu Consent Form

Name *

First Name Last Name

Facility Name *

Sex *

Date of Birth *

Date

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Social Security Number *

Upload Insurance Information

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Vaccine is for (check one) *

Self

Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers? *

YES NO

Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness? *

YES NO

Has the person received a live vaccine within the past 30 days (i.e. MMR, RotaTeq/Rotarix)? *If YES, it is recommended to space live vaccines by > 4 weeks for full efficacy *

YES NO

Is the person receiving the vaccine pregnant? *

YES NO

Is the person receiving the vaccine allergic to Neomycin, Thimerosal (Preservative found in contact lens solution), any vaccine ingredient, or latex? *

YES NO

Is the person being administered the regular or high-dose flu vaccine? *

Regular Dose High Dose (Over 65)

I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine. *

Print Name

Staff Influenza (Flu) Consent Form