Quadrivalent Inactivated Influenza Vaccine Consent
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1CAMPUS HEALTH CENTER | 5200 Anthony Wayne Drive, Suite 115, Detroit, MI 48202 | (313) 577-5041
2017-2018 QUADRIVALENT INACTIVATED INFLUENZA VACCINE CONSENT
NAME: _________________________________________ DOB: ____________
AGE:_________ Sex: Male /Female
Please read and check your answer to the following questions:
__Y
__N
Have you had a fever of 101 F. or higher in past 48 hours?
__Y
__N
Have you ever had an allergic reaction to a previous influenza vaccination?
__Y
__N
Do you have a severe allergy to eggs?
__Y
__N
Have you ever had Guillan Barré Syndrome (a severe paralytic illness)?
__Y
__N
Do you have an illness or take medication causing immunodeficiency?
__Y
__N
Are you allergic to any medications? (please list):
__Y
__N
Are you currently taking medicines on a regular basis? (please list):
__Y
__N
I would like to receive the INFLUENZA vaccination from the Campus Health Center.
__Y
__N
I have read the Vaccine Information Statement (VIS) dated 08/07/2015 provided me about
INFLUENZA vaccine and the benefits and risks associated with receiving INFLUENZA
vaccination.
I certify that I have read this form, that I fully understand the authorizations, acknowledgements, consents and
waivers given above, that I was given ample opportunity to ask questions and that any questions have been
answered satisfactorily. The signature below indicates my request and consent for the INFLUENZA
vaccination.
________________________________________________
________________________
Signature
Date
Office Use Only
UI852AB
Vaccine: Fluzone
Manufacturer: Sanofi
Lot #:
Expires: 06/30/2018
Dosage: 0.5 cc IM
Site: R or L Deltoid
Administered by:
Date:_______________________________________
Revised 10/03/2017
A healthy YOU
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Parent category: Legal