Influenza Vaccination Consent Form Page 2
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2Flu Vaccination Information
Prior to an injection of any vaccine, all known precautions
PRECAUTIONS:
should be taken to prevent potential reactions. This
includes a review of the patient's medical history with
Inquiry regarding previous hypersensitivity should
respect to possible allergic reaction or sensitivity to the
precede
the
administration
of
the
influenza
vaccine. This also includes a previous immunization
vaccine.
history and up to date health evaluation.
Vaccination should be postponed in patients
suffering from any acute illness although minor
The
influenza
vaccine
is
contraindicated
in
infections without fever or systemic upset are not
person's sensitive to egg, chicken or influenza
regarded as contra-indications.
viral protein.
Caution should be observed in patients with less
Immunization should be delayed if there is active
severe
manifestations
of
antibiotic
or suspected infection.
hypersensitivity.
The vaccine should not be given to patients with a
Measures
to
treat
anaphylaxis,
including
history of anaphylaxis to polymixin and neomycin.
adrenaline should be immediately available.
The vaccine should not be given to anyone that is
Before injection of a vaccine any alcohol or
allergic to Thimerosal (a Mercury derivative)
disinfectant used for cleansing the skin should be
allowed to evaporate.
SIDE-EFFECTS and SPECIAL PRECAUTIONS:
Influenza vaccine should not be administered
during pregnancy unless it is considered that
Local reaction, possibly with inflammation and
there is a significant risk of exposure to infection.
lymphangitis. At the site of injection an induration
As with any vaccine, vaccination with influenza
or sterile abscess may develop. Fever and malaise
vaccine may not protect 100% of recipients from
sometimes occur and severe febrile reactions
influenza
have been reported.
Hypersensitivity
reactions
may
occur
and
anaphylaxis has been reported in some cases.
Various
neurological
syndromes
have
been
temporally
associated
with
administration
of
influenza vaccine, the most notable report being
Guillain-Barre'
syndrome
occurring
after
vaccination
with
inactivated
swine
influenza
vaccine in 1976.
Influenza vaccination has been associated with
development
and
exacerbation
of
Henoch-
schoniem purpura.
OccuVAX LLC, 2013
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