Influenza Vaccine Consent Form - Chantilly Family Practice Center printable pdf download

Influenza Vaccine Consent Form - Chantilly Family Practice Center

INFLUENZA VACCINE CONSENT FORM

INFLUENZA (Flu) is a viral infection of the bronchial tubes and lungs that is characterized by

abrupt onset of fever, myalgia (body aches), sore throat and non productive cough. Unlike

other common respiratory infections, influenza can cause severe malaise lasting several

days. Bacterial pneumonia is a common complication of influenza.

INFLUENZA VACCINE QUESTIONNAIRE

Are you allergic to egg/chicken?

Yes

Have you had flu shot in the past?

Yes

Have you had any reactions to flu in the past?

Yes

Any fever in the last 24 hours

Yes

Are you pregnant? Possibility of pregnancy?

Yes

SIDE EFFECTS OF THE VACCINE

Most people have no side effects from the influenza vaccine. The most frequent side effects

of the flu vaccine is soreness around the injection site that last up to two (2) days. Other

possible side effects include fever, malaise, muscular pain (myalgia). These can begin 6-12

hours after vaccination and can persist for 1-2 days. Immediate reactions such as hives

angioedema, allergic asthma, or systematic anaphylaxis “rarely occur.” If you think you may

be having these reactions, please call 911 or go to the nearest emergency room.

I understand this vaccine is being offered on a voluntary basis to individuals who wish to

reduce their risk of acquiring influenza infection. I understand the benefits and risks of this

vaccine and do voluntary request that it be given to me. I have also provided the answers

to the above questions truthfully.

__________________________________________

_______________________________

Patient / Parent or Guardian’s Signature

Date

__________________________________________________________________________________________

Patient’s temperature __________

Time administered __________

Dose __________

Lot # _______________

Expiration date _______________

Site given ______________

Staff signature _________________________________

Date ________________________

Form AR-035

Influenza Vaccine Consent Form - Chantilly Family Practice Center