Influenza Vaccine Consent Form (Adults) 2015-16 printable pdf download

2015-16 Influenza Vaccine Consent Form (Adults)

Little Silver Pediatrics & Family Medicine is committed to healthy families and communities. We are pleased to

offer preservative-free flu vaccine to protect our pediatric and adult patients. To keep our community safe from flu,

we urge all families to consider getting the Influenza vaccine this season. We accommodate children and parents

during the same visit. Vaccination is by appointment only. To schedule an appointment, please call (732)

Health1 or (732) 741-5600

The Centers for Disease Control and Prevention (CDC) recommendations for the 2015-2016 flu season are

posted at

Before Your Visit: Please complete this form and bring it along for your visit. Review the Vaccine Information Sheet (VIS)

published by the Centers of Disease Control at

. A copy will also

be provided for you to review at our office and before the vaccine is administered.

Please complete the consent form. You must bring a completed and signed form to receive the Flu Vaccine.

Section I: Information about the Person Receiving the Vaccine

Name: ___________________________________________ Date of Birth ___________________________

Address: _____________________________ City ______________ State NJ

Zip _______ Tel:__________

If pregnant, your expected date of delivery_____________ Your Obstetrician___________________________

Section II: Screening for Vaccine Eligibility:

The following questions will help guide us about whether you can receive the 2011-12 influenza vaccine. Please mark YES or

NO for each question. If you answer “NO” to all the 7 questions, you can probably get the influenza vaccine. If you answer

“YES” to one or more of the 7 questions, you should discuss your options with your primary physician. If pregnant, please

discuss your options with your obstetrician.

Have you had fever or been sick during the last seven days?

Yes

Do you have a serious allergy to eggs?

Yes

Do you have any serious allergies to the following:(check)

gelatin

polymixin

gentamycin

neomycin

Do you have any other serious allergies? Please list below:

_____________________________________________________________________________________________

Have you had a serious reaction to a previous dose of the flu vaccine

Yes

Have you had Guillain-Barre’ Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu

vaccine?

Yes

If Pregnant, have you experienced any problems with your pregnancy

Yes

No. If yes, please describe below:

______________________________________________________________________________________________

Section III: Consent & Permission To Release Information

I have read the 2015 Vaccine Information Statement published by the US Centers for Disease Control and Prevention for the

Influenza vaccine, had my questions answered, and understand the risk and benefits. I give consent to Little Silver Medicine

(administrator) and its staff to be vaccinated with the Influenza vaccine (inactivated, preservative-free). I have read the notice

for consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations and give consent

for release of data from the vaccination record for reporting to the CDC, administrative purposes, and, for community health

improvement.

_______________________________

_____________________________________

Signature

Date: Month / Day

Year

Vaccine

Admin Date

VIS-Flu

Route

Manufacturer

Lot Nu.

Administrator

Influenza

8/7/2015

Sanofi

D Mehra,MD

N Mehra,MD

200 White Road, Suite 212

• Little Silver, NJ 07739

• Tel: (732) 741-5600

• Fax: (732) 345-1001

Influenza Vaccine Consent Form (Adults) 2015-16

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