Influenza Vaccination Consent Form printable pdf download

Caremark ID# ____________

Influenza Vaccination Consent Form

(Please see reverse side for Flu Vaccination Information)

Clinic Location:

______________________Clinic Date:

_______

Patient Name:

Birth Date:

____Phone: (

)

Address:

City/State/Zip

Before getting an Influenza vaccination

please

check YES or NO to the following questions:

Have you received flu vaccinations before? ................... ___YES ___NO

Are you pregnant or breast feeding? (If yes, you will need permission,

preferably written but not required, from your doctor to receive the flu

YOUR VACCINATION WILL

vaccine)……………………………………………………………….……………… ___YES ___NO

Do you have a fever today? ........................................ ___YES ___NO

NOT BE BILLED TO YOUR

Do you have an allergy to chicken eggs,

egg products, or latex? ……………………………………………………

___YES ___NO

INSURANCE.

Do you have cold or flu symptoms today? ……………………… ___YES ___NO

Have you ever had a neurological disorder or have you been diagnosed

with Guillain-Barre' Syndrome? ………………………………..……… ___YES ___NO

IF YOU NEED PROOF OF

Do you have any health problems or allergic disorders that require you to

currently see a physician?........................................... ___YES ___NO

VACCINATION, PLEASE

If yes, please explain:_________________________________________

REQUEST AT TIME OF

___________________________________________________________

Do you have a known allergy to thimerosal, a derivative of mercury? (i.e.

VACCINATION.

merthiolate, eye contact solution) …………………………………… ___YES ___NO

Have you ever had a reaction to a flu shot? ……………….….. ___YES ___NO

If yes, please explain:_________________________________________

___________________________________________________________

I am providing this consent form to OccuVax in order that I may be given the influenza vaccination.

I have read and understand the information I have

received concerning the possible benefits and side effects of the influenza vaccination. I hereby acknowledge that, based on the information presented

to me, I am eligible to receive the influenza vaccine on this date. I am feeling well today and I have not recently had a fever. I understand that no

assurance can be given that the influenza vaccination will give me immunity from contracting any strain of influenza.

I hereby acknowledge that I have received a copy of the OccuVax, Notice of Privacy Practices that has an effective date of July 2014.

I release OccuVax, its employees, representatives and agents from any liability for giving me the influenza vaccination. I agree to indemnify, defend

and hold OccuVax harmless from any claim. I accept responsibility for seeking medical attention for any problems associated with my receiving the

influenza vaccination. I have had the opportunity to have my questions answered.

Signature:

____________________________________

Date:

**For OccuVAX Nurse use only**

Influenza:

Site/Dose;* /0.5ml given IM, L___ R___

Mfg:

ot:_______

Deltoid

*(Assuming R deltoid if none noted)

____________________________

_____________________________________________________

Administered by

(Nurse Signature)

Influenza Vaccination Consent Form

Related Articles

Related forms

Related Categories