Annual Influenza Vaccine Consent Form - Flu Shot
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1
2Annual Influenza Vaccine Consent Form-FLU SHOT
STUDENT’S NAME
DATE OF BIRTH
STUDENT’S AGE
PARENT/LEGAL GUARDIAN’S
Parent/Guardian’s
Grade:
Teacher :
NAME (Last)
Daytime Phone #:
NAME
PRIMARY CARE
OF
PHYSICIAN:
The State of VT provides the Flu Vaccine for our school flu clinics. They require the following information in order to
provide the vaccines; Is the Federally Vaccine-eligible Child:
1. An American Indian or Alaskan Native: (Circle One) Yes No
2. Enrolled in Medicaid: Yes No
3. Has no other health insurance: Yes No
4. Underinsured (child has health insurance, but the coverage does not include vaccines: Yes No
Screening for Vaccine Eligibility:
The following four questions will help us to know if your child can get the influenza vaccine.
YES
NO
If you answer “YES” to one or more of the following questions, your child may be able to get the
influenza vaccine, but we will contact you to discuss your options.
1. Does your child have a serious allergy to eggs?
2. Does your child have any other serious allergies? Please list:
3. Has your child ever had a serious reaction to a previous dose of flu vaccine?
4. Has your child ever had Guillain-Barré Syndrome (a type of temporary severe muscle
weakness) within 6 weeks after receiving a flu vaccine?
CONSENT FOR VACCINATION:
I have read or had explained to me the 2017-2018 Vaccine Information Statement for the seasonal influenza vaccine and
understand the risks and benefits.
I Give Consent to UPPER VALLEY PEDIATRICS and its staff for my child named at the top of this form to be
vaccinated with seasonal flu vaccine at Thetford Academy. (If this consent form is not signed your child will not be
vaccinated.)
Signature of Parent/Legal Guardian ___________________________________ Date: ______________
Section 5: Vaccination Record
FOR ADMINISTRATIVE USE ONLY
Vaccine
Route
Date
Vaccine
Lot
Name and Title of Vaccine
Administered
Manufacturer
Number
Administrator
Influenza IM
Sanofi Pasteur
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