Flu/Pneumonia Consent Form

Influenza/Pneumococcal Vaccine Consent Form

Vaccine consent form
Vaccine Recipient Name*

First NameMiddle NameLast Name
Address*

Street Address

Apt #

CityState Initials

Zip Code
Phone Number*
Email
example@example.com
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Choice of Vaccine

High Dose Flu Vaccine fo 65+ yrs old (Quadri-Valent, High Dose, Preservative free)Flu Vaccine (Quadri-Valent, Preservative free)Pneumonia Vaccine (Prevnar 20)

	Yes	No
1. Are you feeling sick with fever today?
2. Have you ever had a life threatening allergic reaction to acomponent (or part) of the flu or pneumonia vaccine?
3.Have you ever developed Guillain-Barre Syndrom within 6 weeks of receiving flu or pneumonia shot?
4. Have you ever had pneumonia shot?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to eggs or egg products?
6. Have you received any vaccine in the last 4 weeks?
7. Are you currently pregnant?
8. Do you have history of asthma or wheezing?
9. Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care?
10. Have you taken an antiviral medication for the flu with in the last 48 hours?
11. Are you a child or adolescent receiving long-term aspirin therapy?

Vaccuine Information Sheets:

Flu VIS in English

https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf

Flu VIS in Spanish

https://www.immunize.org/vis/spanish_flu_inactive.pdf

Pneumonia VIS in English

https://www.immunize.org/vis/pcv.pdf

Pneumonia VIs in Spanish

https://www.immunize.org/vis/spanish_pcv.pdf
Consent: I have read, or had explained to me, the vaccine information statement about the vaccine I'm about to receive. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. I request that the vaccination be given to me (or the person named above for whom I am authorized to make this request). I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for the other public health purpose. I have received a copy of the Patient Bill of Rights

Clear
Date Signed

MonthDayYear
Date
Primary Care Provider Name
Phone Number of Emergency Contact*
Pharmacist Signature

Clear
Immunizer Name
First and Last Name
Immunizer Signature

Clear
Lot Number
Expiration Date:
Pharmacy Name
Pharmacy NPI*
Should be Empty:

Influenza/Pneumococcal Vaccine Consent Form