Flu Shot Consent Form
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1Flu Vaccine Form
Patient Name:
Date:
F:
M:
DOB:
Age:
Phone:
Address:
City:
State:
Zip:
I, the undersigned, have read or had explained to me the vaccine information sheet (VIS). I
understand the risks and benefits associated with the influenza vaccine and have had any
questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the
aforementioned person for whom I am authorized to make this request.
Signature
Date
Screening Questionnaire
Are you currently ill or do you have a fever?
Yes
No
Unknown
Have you received the vaccine before?
Yes
No
Unknown
Have you had a reaction to the vaccine before?
Yes
No
Unknown
Have you been sick in the last 2 weeks?
Yes
No
Unknown
Are you allergic to egg or dairy products?
Yes
No
Unknown
Are you allergic to thimerosal?
Yes
No
Unknown
Are you pregnant?
Yes
No
Unknown
Are you a Health Care worker?
Yes
No
Unknown
Have you ever had Guillain-Barre syndrome?
Yes
No
Unknown
Do you have a blood-clotting disorder?
Yes
No
Unknown
Are you taking blood-thinning medication?
Yes
No
Unknown
For Office Use Only
Date Given:
Manufacturer & Lot #:
Exp. Date:
Site:
RT
LT
RD
LD
Route:
Administered By:
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