Fillable Printable 2014-2015 Inactivated Influenza Vaccine Consent Form

2014-2015 Inactivated Influenza Vaccine Consent Form

Name of Individual to be Immunized _____________________________________________________

Address ___________________________________________________ Phone # __________________

Date of Birth_______________________________ Age______________ M F

ID# ___________________________________

Please answer the following questions:

Are you sick or do you have a high fever today? Yes  No  Unknown 

Are you allergic to chicken, eggs, or egg products? Yes  No  Unknown 

Have you ever had an allergic reaction to a flu shot? Yes  No  Unknown 

Are you pregnant, or think you may be? Yes  No  Unknown 

Do you have a blood clotting disorder or are you taking

blood thinning medication? Yes  No  Unknown 

Acknowledgement:

1. I am at least 18 years of age. I have read or have had explained to me the inactivated influenza

vaccine: “What you need to know”, vaccine information sheet. I have been given the opportunity to

ask a USC health care professional concerning the influenza vaccine, including the risks and benefits

of receiving the influenza vaccine. All of my questions concerning the vaccine have been answered

to my satisfaction. I understand the benefits and risks of the influenza vaccine and request that it be

given to me.

2. I affirm that I am not allergic to eggs, chicken, thimerosal, albumin products or a previous dose of the

influenza vaccine. I do not have a history of Guillain-Barre’ Syndrome (GBS).

3. I understand my medical care provider may submit this immunization information to the state

immunization registry.

Release of Liability:

I have read and I understand the acknowledgements set forth above, and I hereby release the University

of Southern California and USC Care Medical Group and their affiliated entities, and all of their agents,

employees, trustees, and representatives, from an y and all liabilit y which may arise from the vaccination

and/or from the information provided to me concerning such vaccination.

Consent to the Vaccination:

I have read and I understand the informat ion set forth i n this form. Based on that understanding, I hereb y

CONSENT to an inactivated influenza vaccination provided to me by USC Care Medical Group.

______________________________________________ _________________________

Signature of Recipient of the Vaccination Date

If signed by someone other than recipient, please indicate name and relationship. _______________________________

___________________________________________________ _________________ ______________________________________

Signature of Witness Date Printed Name of Wit ness

For Office Use Only

Flu vaccine Lot #: _____________ Exp: __________ Date: ____________ _______

Site of I njection : R L Deltoid ________________