Flu Vaccine Consent Form - Pediatric Alliance, Pc printable pdf download

Flu Vaccine Consent Form - Pediatric Alliance, Pc

FLU VACCINE CONSENT FORM

I voluntarily submit to and authorize PEDIATRIC ALLIANCE to administer the flu vaccine to me/my child for the

purpose of immunizing against influenza and have reviewed the Vaccine Information Statement. I have had a chance to

ask questions and understand the information presented to me.

I understand that if this is not a covered service under my insurance, that I will be responsible for the cost.

Inactivated Influenza Vaccine

Contraindications:

Check any of the following that apply to you:

A history of an allergy to egg products or gelatin

Severe allergies to flu vaccines in the past

Acute respiratory illness with a fever

A history of Guillian-Barre Syndrome or active neurological disorder

Currently on long-term steroids

Sensitivity to latex

I understand that occasional reactions may occur and these may include:



Local reactions: soreness at the vaccine site



Systemic reactions: fever, aches



Immediate or allergic reactions: In rare cases a serious allergic reaction may occur. Signs of a serious allergic

reaction may include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat or

dizziness.

I have read the contraindications above and have discussed any concerns with my healthcare provider.

I understand that I am to report to the nearest Emergency Department if a severe reaction occurs.

Patient Name: _______________________________________________

DOB: ________________

Parent/Guardian Signature: __________________________________________________

Date: _________________

Site:

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LA______ RT_______ LT_______

2016-2017

Flu Vaccine Consent Form - Pediatric Alliance, Pc