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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:

Please print:

(FIRST) (MIDDLE) (LAST)









*If YES, it is recommended to space live vaccines by > 4 weeks for full efficacy



(If no, the child will need to receive 2 vaccinations [at least one month apart] for the best protection against flu.)