Influenza Vaccination Consent Form
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2Influenza Vaccination Consent Form
Note: you must remain in the clinic area 15 minutes after the injection (or 30 minutes if you have an egg allergy)
Last name
First name
Male
Female
Date of birth
Address
Home phone #
Work phone #
Cell phone #
Do you have any chronic medical condition(s)?
No
Yes
(ie. diabetes, asthma, heart disease, hepatitis, etc.)
Do you have any allergies?
No
Yes
I have read the information about the influenza vaccine on the back of this consent form. I have had the chance
to ask questions which were answered to my satisfaction. I understand the benefits and risks associated with
this vaccine.
Signature
Date
FOR CLINIC USE ONLY
I have used (2) client identifiers and the client has no contraindications to receiving the influenza vaccine based
on the review of all screening questions.
Vaccine: Vaxigrip
Lot number: C4595AA
Expiry date: June 2014
Dose: 0.5 mL IM
Site:
Left arm
Right arm
Left thigh
Right thigh
Date
Nurse’s signature
Time
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Parent category: Legal