Printable Flu Vaccine Consent Form As some influenza SLV programs do not offer second doses of influenza vaccine these consent forms were developed for programs administering only one influenza vaccine to students If a second dose of influenza vaccine will be offered additional information about influenza vaccination histories may need to be collected
Flu Print Resources Print loading 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 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 Current Medications Allergies drug food
Printable Flu Vaccine Consent Form
Printable Flu Vaccine Consent Form
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Influenza vaccine can prevent influenza flu Flu is a contagious disease that spreads around the United States every year usually between October and May Anyone can get the flu but it is more dangerous for some people Infants and young children people 65 years and older pregnant people and people with certain health conditions or a weakened immune system are at greatest risk of flu 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
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 Consent Form Updated 10 2019 Influenza Quadrivalent Vaccine Consent Form Section 1 Information for Individuals receiving the 2019 20 Quadrivalent Influenza Vaccine please print First and Last Name please print Date of Birth Signature Date Title 2009 H1N1 Influenza Vaccine Consent Form for Use With Either Intramuscular Injectable
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Administered Influenza Vaccine 0 5 ml IM Right Deltoid FLUCELVAX Quadrivalent Left Deltoid Lot Number P100347552 Expiration date 6 2 2022 Lot Number 308519 Expiration date 6 30 2022 Lot Number 308520 Expiration date 6 30 2022 Patient instructed to notify physician immediately for any significant reaction 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 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 Changing Each year a new flu vaccine is made to protect against the influenza viruses believed to be likely to cause disease in the upcoming flu season Even when the vaccine doesn t exactly match these viruses it may still provide some protection Influenza vaccine does not cause flu Influenza vaccine may be given at the same time as
Free Flu Shot Influenza Vaccine Consent Form PDF Word EForms
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https://www.cdc.gov/flu/school/slv/support.htm
As some influenza SLV programs do not offer second doses of influenza vaccine these consent forms were developed for programs administering only one influenza vaccine to students If a second dose of influenza vaccine will be offered additional information about influenza vaccination histories may need to be collected
https://www.cdc.gov/flu/resource-center/freeresources/index.html
Flu Print Resources Print loading 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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Printable Flu Vaccine Consent Form Template Printable Word Searches
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Printable Flu Vaccine Consent Form - Influenza vaccine can prevent influenza flu Flu is a contagious disease that spreads around the United States every year usually between October and May Anyone can get the flu but it is more dangerous for some people Infants and young children people 65 years and older pregnant people and people with certain health conditions or a weakened immune system are at greatest risk of flu
