Flu shot consent form pdf

The choice of which consent form s to distribute to parentsguardians will depend on which vaccine formulation liveattenuated intranasal vaccine laiv, inactivated injectable vaccine, or both will be offered at the slv clinic. Seasonal influenza vaccine consent form 2018 community program adult i consent to the personal details below being used by nsw health for administration and evaluation purposes. The document ensures that the receiver of the vaccination is aware of the process and side effects, and that theyve had ample opportunity to field any questions they may have. Infants and young children, people 65 years of age and older, pregnant women, and people with certain health conditions or a weakened immune system are at greatest risk of. Inactivated influenza vaccine consent and administration.

Microsoft word flu vaccine consent form 20182019 author. This flu shot consent form is designed to by given out by medical professionals and completed by patients agreeing to a. Tell your health care provider if a child who is getting flu vaccine. They may be printed on a standard office printer, or you may use a commercial printer. Talk to your healthcare professional about the benefits and possible risks. On this page, members will find forms and resources e. Take advantage of each office visit as an opportunity to encourage patients to protect themselves from the flu and serious complications by getting a flu shot. The influenza vaccination provider toolkit has been developed to assist providers with managing rollout and implementation of their flu vaccination program in 2020.

Flu consent forms printable fill out and sign printable. This form includes a series of questions that can help to exclude patients who are at risk for complications and those who otherwise. I understand the risks and benefits associated with the influenza vaccine and have had any questions satisfactorily answered. I have received and read the cdc vaccine information statement for the inactivated influenza vaccine 08152019 and i understand the benefits and risks. Flu vaccination record keeping and data requirements. Fill out, securely sign, print or email your flu shot forms instantly with signnow. The nasal flu vaccine contains products derived from pigs porcine gelatine. Young children who get the flu shot along with pneumococcal vaccine pcv, andor dtap vaccine at the same time might be slightly more likely to have a seizure caused by fever. If yes to any questions then do not vaccinate with influenza vaccine.

The most secure digital platform to get legally binding, electronically signed documents in. Influenza immunization ontario pharmacists association. Screening checklist for contraindications to inactivated injectable influenza vaccination patient name date of birth for patients both children and adults to be vaccinated. On the document there is a series of yesorno questions which must be answered. Contraindications include severe allergy to eggs some vaccine influenza is grown in hens eggs or any other vaccine. I have read and understand the information i have received concerning the possible benefits and side effects of the influenza vaccination. In light of the general data protection regulations and to facilitate the expansion of the postpayment verification process to cover the flu vaccination service, the consent form and record form were separated into two different forms. My employer or affiliated health facility, recommends that i receive influenza vaccination to protect myself, patients, staff, and others in the healthcare facility. Tell your health care provider if a child who is getting flu vaccine has ever had a seizure. Further, i hereby give my consent to the healthcare provider of walgreens, duane. Flu vaccine consent form fill out and sign printable pdf. The most secure digital platform to get legally binding, electronically signed. Flu vaccine varies in how well it works, and unfortunately, some people can become infected with a flu virus that a flu vaccine. Complete this form when attending a flu shot clinic for um system keywords.

Vaccine administration record var informed consent for vaccination healthcare providers can be an immunizationcertified pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner, physician or physicians assistant. A pdf of the consent form will open in a new window. Influenza is a contagious respiratory illness that spreads from person to person through coughing, sneezing or close contact. Vaccine administration record var informed consent for. I, the undersigned, have read or had explained to me the vaccine information sheet vis. In the case of a severe reaction such as a high fever, behavior changes or flu like symptoms that occur after vaccination, see a doctor right away.

I understand that in the course of the requested vaccine administration, an heb pharmacy representative could possibly be exposed to my blood or bodily fluids. The 201920 influenza vaccines protect against the following viruses. Click on an audience for products in different sizes, formats, and languages. If yes to question 4, vaccinate when resident has recovered. Vaccine administration record var informed consent walgreens. The document ensures that the receiver of the vaccination is aware. Fill out, securely sign, print or email your received flu shot fillable form instantly with signnow. I understand the risks and benefits associated with the influenza vaccine. Information about the 2020 influenza vaccine presentations is available on the influenza vaccine. Seasonal influenza vaccination 2020 immunisation programs. Live vaccines chickenpox, flu nasal spray, mmr ii, oral typhoid, shingles. The document ensures that the receiver of the vaccination is aware of the process and side effects, and that theyve. A flu vaccine is made to protect against the three or four flu viruses that research suggests will be most common. Fill out, securely sign, print or email your flu shot consent form sandy city sandy utah instantly with signnow.

Anyone can get the flu, but it is more dangerous for some people. Patient record of influenza vaccination consentdeclination consent the influenza virus vaccine is recommended for elderly and highrisk patients, their household contacts, healthcare. By signing this consent, i am authorizing the fdohflagler county staff to administer the inactivate influenza vaccine to the person designated on this form. Optout form to the applicable provider andor my state hie, as applicable. Flu shot consent form influenza vaccine the flu shot consent form must be completed before a influenza vaccine is administered. Vaccine administration record var informed consent for vaccination healthcare providers can be an immunizationcertified pharmacist or a registered nurse, licensed practical nurse, licensed. Keep this article and refer to it throughout the 20192020 flu season. Vaccine consent form 20192020 clinic stamp last name. It should be signed by the patient, or, in the case of a minor, by a parent or legal guardian. Because the idea of vaccinating children at school may be unfamiliar to some parentsguardians, there may be reluctance to consent to influenza vaccination at. Influenzapneumococcal immunization consent form influenza consent i have read,or hadexplainedto me, the vaccine information statement about influenza vaccination. Adult influenza flu vaccine registration consent form burlington county health department please print clearly. Have you ever had an allergic reaction to flu vaccine. Fluquadri vaccine consent form medical history before agreeing to receive the flu vaccine, please read the consumer medicine information cmi.

I have hada chance to ask questions, which were answered to my satisfaction, and i understand the benefits and risks of the vaccination. Influenza vaccine can prevent influenza flu flu is a contagious disease that spreads around the united states every year, usually between october and may. The most secure digital platform to get legally binding. Free flu shot influenza vaccine consent form pdf word. If the vaccine is refused due to this content, only children who are at high risk from flu due to a medical condition will be offered an alternative injected vaccine. I know that i am required to have my health insurance card or a copy of both sides with me at the time i receive my flu vaccine. I have verified that my health insurance covers flu vaccine. This seasons flu materials include messaging to address flu recommendations.