Printable Flu Vaccine Consent Form Template Influenza also known as the flu is a respiratory illness that is contagious It is caused by the influenza virus and can infect the throat nose and lungs The disease it causes can range from very mild to severe and possibly death in the most severe cases The best flu prevention is to have a flu shot every year
Last Reviewed December 13 2022 Source Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases NCIRD Everything you need to know about the flu illness including symptoms treatment and prevention Attached is a template letter to providers 32 KB 1 page Having mechanisms in place to disseminate vaccination information to healthcare providers will also help gain backing from local health care providers
Printable Flu Vaccine Consent Form Template
Printable Flu Vaccine Consent Form Template
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The influenza virus vaccine is recommended for elderly and high risk patients their household contacts healthcare personnel and anyone who wishes to reduce the chance of catching influenza DO NOT have any of the conditions listed below Serious allergy to eggs Serious reaction to previous flu vaccine History of Guillain Barre syndrome The information you provide to complete this form indicates you understand the benefits and risks of receiving the influenza vaccine as indicated in the CDC s Vaccine Information Statement VIS and are requesting to be vaccinated Last Name First Name M id le Inta Building Work Location Last 4 digits of SSN Date of BirthCurrent Medications
HEALTH CARE PROVIDER INFLUENZA VACCINE CONSENT FORM 2022 2023 clinic stamp Last name First name Phone number Street Address City Postal Code Male Female Date of Birth Year Month Day I have had a dangerous reaction after eating or handling eggs have had a serious reaction to an influenza vaccination flu shot in the past have been paralyzed with Guillain Barre syndrome am ill with more than a minor cold and have a fever at this time have had a reaction to components in the flu vaccine in the past
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For children 6 mo 8 yrs Have they received 2 or more doses of influenza vaccine since July 2015 YES NO 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 2 Influenza vaccines CDC recommends everyone 6 months and older get vaccinated every flu season Children 6 months through 8 years of age may need 2 doses during a single flu season Everyone else needs only 1 dose each flu season It takes about 2 weeks for protection to develop after vaccination
CONSENT FOR INFLUENZA VACCINE Complete information about person to receive the vaccine Please print clearly Name Date of Birth Age Address City State Zip Code Phone Doctor s Name Sex M F Are you an LVHHN employee Yes No IF YES PLEASE STOP AND ASK FOR EMPLOYEE HEALTH CONSENT FORM Contains thimerosal GSK 6 09 Sanofi CONSENT FOR CHILD S VACCINATION I have read or had explained to me the 2010 2011 Vaccine Information Statement for the seasonal influenza vaccine and understand the risks and benefits I GIVE CONSENT to the NAME OF ORGANIZATION CONDUCTING CLINIC and its staff for my child named at the top of this form to be vaccinated with this vaccine
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Influenza also known as the flu is a respiratory illness that is contagious It is caused by the influenza virus and can infect the throat nose and lungs The disease it causes can range from very mild to severe and possibly death in the most severe cases The best flu prevention is to have a flu shot every year
https://www.cdc.gov/flu/resource-center/freeresources/index.html
Last Reviewed December 13 2022 Source Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases NCIRD Everything you need to know about the flu illness including symptoms treatment and prevention
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