Flu Vaccine Consent Form - Pediatric Alliance, Pc


I voluntarily submit to and authorize PEDIATRIC ALLIANCE to administer the flu vaccine to me/my child for the
purpose of immunizing against influenza and have reviewed the Vaccine Information Statement. I have had a chance to
ask questions and understand the information presented to me.
I understand that if this is not a covered service under my insurance, that I will be responsible for the cost.
Inactivated Influenza Vaccine
Check any of the following that apply to you:
A history of an allergy to egg products or gelatin
Severe allergies to flu vaccines in the past
Acute respiratory illness with a fever
A history of Guillian-Barre Syndrome or active neurological disorder
Currently on long-term steroids
Sensitivity to latex
I understand that occasional reactions may occur and these may include:
Local reactions: soreness at the vaccine site
Systemic reactions: fever, aches
Immediate or allergic reactions: In rare cases a serious allergic reaction may occur. Signs of a serious allergic
reaction may include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat or
I have read the contraindications above and have discussed any concerns with my healthcare provider.
I understand that I am to report to the nearest Emergency Department if a severe reaction occurs.
Patient Name: _______________________________________________
DOB: ________________
Parent/Guardian Signature: __________________________________________________
Date: _________________
LA______ RT_______ LT_______


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