Fillable 2015 Influenza Vaccine Participation And Consent Form printable pdf download

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2015 INFLUENZA VACCINE PARTICIPATION AND CONSENT

Precautions & Contraindications – Please read & answer EVERY question CAREFULLY.

Have you received flu vaccinations before?

YES

Have you ever had an allergic reaction to a flu vaccine?

YES

**If you answered yes to

Are you allergic to eggs or egg products?

YES

any of these questions

Are you allergic to thimerosal (a mercury-based preservative)?

YES

(except for the first one), a

Are you allergic to neomycin or polymyxin?

YES

health care professional will

Are you allergic to latex?

YES

determine if the influenza

Do you feel ill today or do you have a fever?

YES

vaccine is right for you

today. **

Have you been told you have/had Guillain-Barre Syndrome?

YES

Are you pregnant? # weeks_________

YES

Before you can receive the influenza virus vaccine, you must read the provided Influenza Vaccine Information Sheet, answer the above

questions, and have the health care professional administering the vaccine review your answers. The health care provider will keep this form

and related information in a confidential manner.

I understand there are risks associated with all vaccines, and that like any vaccine, the influenza virus vaccine does not protect 100% of

individuals vaccinated. I have received the Influenza Vaccine Information Sheet, and I have read or have had explained to me the information

in this sheet about the influenza viral vaccine. I have had a chance to ask questions. I understand the benefits and risks of the influenza vaccine.

My signature below indicates my permission for the influenza vaccine to be given to me or the person named below for whom I am authorized

to make this request. I assume full responsibility for any reactions that may result and I waive and release all claims I, or anyone claiming by or

through me, now have or may hereafter acquire against the Curators of the University of Missouri, its officers, directors, employees, agents,

volunteers and representatives for any and all damages or injuries if I or the person named below for whom I am authorized to make this request

contract influenza, other diseases, or suffer any other adverse reactions following administration of this influenza shot.

Signature

Signature of guardian (if under 18)

Date

For Office Use Only

Covered for UM faculty or staff, dependents or retirees enrolled in UM Health Plans OR

$20 cash/check for UM faculty or staff or dependents NOT enrolled in UM Health Plans.

Information about person to receive vaccine:

$20 cash / check #_________

Vaccine Information

Statement Date:

DOB (Date of Birth):

8/7/2015

Site of Injection:

First Name:

Last Name:

L or R Deltoid

Date of Vaccination:

Home Address: _________________________________________________

_______/_______/2015

City/State/Zip: _________________________________________________

Phone: (

)

Coventry Member Number:

Manufacturer:

Novartis/Flucelvax

___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___

Lot #: 173538

Expiration Date: 04 / 30 / 2016

MEMBER NAME: JOHN SMITH

Dose/Route of Vaccine: 0.5mL IM

MEMBER NUMBER: 0123456789-01

Signature of person giving

Family Physician: _______________________ Phone: (

) ______-___________

vaccine:

Address: _______________________________ Fax: (

) ______-___________

City/State/Zip:

Supervisor:

2015 Influenza Vaccine Participation And Consent Form

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