Fillable Printable Patient Consent Form for Seasonal Influenza Vaccine

Patient Consent Form for Seasonal Influenza Vaccine

Insert Facility Logo

PATIENT CONSENT FORM

FOR SEASONAL INFLUEN Z A V ACCINE

I have read, or have had explained to me, the CDC Vaccine Information Statement about influenza and the

influenza vaccine. I understand that this vaccine may cause flu-like symptoms in some people and in rare

incidents Guillain-Barré syndrome. I have had an opportunity 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 me

(or person named below for whom I am authorized to make this request).

Please print:

Name: __________________________________________________________ Date of Birth: ____/____/____

(FIRST) (MIDDLE) (LAST)

Parent or Guardian’s Name (if applicable): ________________________________________________________

Has the person receiving the vaccine ever had a severe allergic (hy persensitivity) reaction to eggs, chickens, or

chicken feathers? ____Yes ____No

Does the person receiving the vaccine have a history of Guillain-Barré sy ndrome or a persistent neurological

illness? ____Yes ____No

Is the person receiving the vaccine pregnant? ____Yes ____No

(If yes, LAIV c ontraindicated, TIV recommended)

Is the person receiving the vaccine allergic to Thimerosal (Preservative found in contact lens solution), any

vaccine ingredient, or latex? ____Yes ____No

For child 6 mo-8 yr s, have they received 2 or more doses of influenza vaccine since July 2010? ___Yes___No

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

________________________________________________________ ___ ___ ___ ____________ ___ _______

Signature of person receiving vaccine OR Parent/Guardian Date

DO NOT WRITE IN THIS SPACE—OFFICE USE ONLY VIS Edition Provided: ________________

Lot number: ________________________Expiration Date: _______________ Dose #1 or Dose #2

(Circle One - Pediatric Only)

LAIV Nasal spray is recommended for children aged 2-8 (older adolescents and adults may receive as

well if stock allows).

CHECK ONE:

___ 0.5 mL IM Influenza Virus Vaccine given in ___left ___right deltoid – TIV or QIV

___ 0.5 mL IM Influenza HIGH Dose Virus Vaccine given in ___left ___right deltoid (65+) TIV-SR

___ 0.2 mL Li ve Attenuated Influenza Virus Vaccine given intranasally (half each nostril)

___ 0.5mL FluBlok Influenza Virus Vaccine given in ___left ___right deltoid

___ Children 6-35 months: 0.25 mL/dose given in ___left ___right deltoid (1 or 2 doses per season)

___ Children 3-8 ye ars: 0.5 mL/dose given in ___left ___right deltoid (1 or 2 doses per season)

___ Children older than 9 years: 0.5 mL/dose given in ___left ___right deltoid (1 dose per season)

_________________________________________________________ __________________ _________

Nurse/MA/Pro vider ’s Si gna tur e Date Time