Influenza Vaccine Consent Form - City Of Ottawa Page 2
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3INFLUENZA VACCINE CONSENT FORM
NOTE: You must remain in the clinic area 15 minutes after the needle is given
(30 minutes if you have a mild egg allergy).
Last Name:
First Name:
(Male) (Female)
Year
Month
Day
Age
Date of birth:
Address:
Street
Unit/Apt. #
City
Postal Code
Day: (
)
Evening: (
)
Telephone:
Do you have a chronic medical condition? (i.e. diabetes or a condition affecting
No
Yes
your heart, lungs, immune system and/or kidneys, etc. )
I have read the information about the flu vaccine on the back of this consent form. I have had the chance to ask
questions which were answered to my satisfaction. I understand the benefits and risks associated with this vaccine. I
give consent to receive the flu vaccine.
Signature: X
Date:
For Clinic Use Only
The client has no contraindications to receiving the influenza vaccine based on the review of all
screening questions.
RN/RPN Initials
Vaccine: Vaxigrip ® :
Dose: 0.5 mL intramuscular
Lot Number
Site: Right arm
Agriflu ® :
Left arm
Lot Number
Right thigh
Fluviral ® :
Left thigh
Lot Number
RN signature
Date/TIme
RPN signature
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