Precision LTC Flu Form
CONSENT FORM FOR SEASONAL INFLUENZA (FLU) VACCINE
I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice before coming here today. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine and request that the vaccine be given to:
(FIRST) (MIDDLE) (LAST)
Date of Birth
Parent or Guardian’s Name:
Vaccine is for (check one):
Family Member (Adult)
Family Member (Child)
Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers?
Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness?
Has the person received a live vaccine within the past 30 days (i.e. MMR, RotaTeq/Rotarix)?
*If YES, it is recommended to space live vaccines by > 4 weeks for full efficacy
Is the person receiving the vaccine pregnant?
Is the person receiving the vaccine allergic to Neomycin, Thimerosal (Preservative found in contact lens solution), any vaccine ingredient, or latex?
For children 6 mo-8 yrs: Have they received 2 or more doses of influenza vaccine since July 2015?
(If no, the child will need to receive 2 vaccinations [at least one month apart] for the best protection against flu.)
For children and adolescents aged 2-17 yrs: Is the child taking long-term aspirin or aspirin-containing therapy?
Is the person being administered the regular or high-dose flu vaccine?
Signature of person receiving vaccine OR Parent/Guardian:
( - ) show alternative signature box
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