Flu Vaccine Consent Form printable pdf download

2016-2017 Influenza Immunization Consent Form

Name: _______________________

Account #: ____________________

Date of Birth: _____________________

Practitioner:

Dr. Chung

Dr. Smith

Age: ________

Please Read and Answer The Following:

1. Have you ever had an adverse reaction to the flu shot or any vaccine?

YES / NO

2. Do you feel unwell today or have a fever?

YES / NO

3. Are you allergic to eggs, neomycin, polymyxin, gentamycin, or thimerosol?

YES / NO

4. Have you suffered from Guillian-Barre Syndrome?

YES / NO

5. If you are female, are you pregnant?

YES / NO

6. Are you in agreement with the administration of an influenza vaccination?

YES / NO

Possible Adverse Effects and Precautions:



The vaccine we are administering today is the standard vaccine that the CDC is recommending for

those aged 6 months and older. If you are 65 or older, you may want to get Fluzone® High-Dose

vaccine that may be available at your local pharmacy or primary care physician.



The influenza vaccine is generally well tolerated.



Occasional discomfort, redness, and swelling at the injection site is the most common side effect.



Fever, muscle pain, and generally feeling unwell occur infrequently within a few hours of vaccination

and may last 1-2 days.



You CANNOT “catch the flu” from the influenza vaccine.



Immediate adverse events such as hives, angioedema, wheezing, or systemic anaphylaxis are a rare

consequence of vaccination. We will have medications to treat an immediate reaction, if necessary.



Scientific researchers decide several months in advance the strains of influenza they most likely expect

to affect the population in the upcoming flu season. Occasionally their research doesn’t always choose

the correct strain, so it is still possible that you may catch the flu despite getting the vaccine. However, if

you have the misfortune of catching the flu, it will likely be less severe if you have received the vaccine.



The best advice to stay healthy is still to always wash your hands frequently, use hand sanitizer, and

refrain from sharing food and drinks with sick people.

Patient Acknowledgement and Consent

I have read and understand this information and consent to receiving an influenza vaccine injection.

Signature: _____________________________

Date: _________________

For Office Use Only

Vaccine Designation-Lot #: __________________________

Exp.Date: _________________

Injection Location: Left / Right Deltoid

Nurses Signature: ______________________________

Date: __________________

Flu Vaccine Consent Form

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