Influenza Vaccine Consent Form - 2017/18 - Pharmasave
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12017/18 INFLUENZA VACCINE CONSENT FORM
Patient Full Name
Date of Birth
(dd/mm/yyyy)
Address
Phone Number
Health Card Number
Male
Female
Gender
Note:
Under BC provincial legislation, pharmacists cannot give
Emergency Contact
injections to children under 5 years of age and cannot administer an
Emergency Contact
intranasal drug to children under 2 years of age.
Phone Number
As of today:
Yes
No
Have you ever had a flu shot before?
Have you ever fainted or had a serious reaction to any previous injection or vaccine(s)?
Have you received any vaccinations in the last 6 weeks?
Do you have a fever, infection, or feel unwell?
Do you have any allergies? Please list:
Do you have any chronic health conditions or immunodeficiencies? Please list:
Are you currently on any medications or immunosuppressants? Please list:
Do you have an active neurological condition?
Are you pregnant or breastfeeding?
Have you received blood products (containing immunoglobulin) in the last 3 months?
PATIENT CONSENT
•
I have read or had explained to me and understand the benefits, side effects and risks of receiving the influenza vaccine.
•
I have had the opportunity to ask questions and I have received satisfactory answers.
•
I agree to stay in the pharmacy for at least 15 minutes after receiving the influenza vaccine.
•
I authorize the pharmacist to administer epinephrine and/or life-saving procedures in the event of a severe allergic reaction.
I consent to receive the influenza vaccine today.
OR
AND:
I consent for my child or dependent to receive the
influenza vaccine today.
Print Name
Signature
Date
PHARMACIST USE ONLY:
Deltoid: R L Other _____
Influenza Vaccine
Other
Administration Site
Notes/Observations (15-30min wait)
Dosage: 0.5mL
IM Intranasal Intradermal
Administration Route
Agriflu
Flulaval Tetra
FluMist
Immunization Date
Fluviral
Fluzone
Other
______________
Immunization Time
Pharmacist Name
Lot No.
RPh License No.
RPh Signature
Expiry Date
Pharmasave Pacific 09/15/2017
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