All children under 13 years of age require parental/legal guardian consent

Last Name

First Name


Male Female

Date of Birth

Your Email




Postal Code

* Please answer all questions

Have you ever had a influenza vaccine before?
Yes No
Do you have a fever or feel sick today?
Yes No
Have you ever had a reaction to the flu vaccine (i.e.: hives, difficulty breathing)?
Yes No
Please Specify The Symptoms
Have you ever had Guillain-Barre Syndrome (GBS), a disease that causes your muscles to stop working?
Yes No
Are you allergic to: Thimerosal (mercury)
Yes No
Are you allergic to: Neomycin
Yes No
Are you allergic to: Gentamicin
Yes No
Are you allergic to: Kanamycin
Yes No
Are you allergic to: Formaldehyde
Yes No
Are you allergic to: eggs / egg products (severe allergy such as hives, difficulty breathing etc.)
Yes No
Do you have a bleeding disorder (i.e.: hemophilia)?
Yes No
Do you take blood thinners (i.e.: aspirin, coumadin, warfarin)?
Yes No
Please Specify Which One
Do you have any problems with your nervous system? (i.e: multiple sclerosis, migraines, dementia, epilepsy, Parkinson’s disease, muscular dystrophy, etc).
Yes No
If you answered “yes” to questions ABOVE , please explain below:
Relationship to person receiving the vaccine (if other than yourself):

  • I agree to remain at the location for 15 minutes or for the duration specified/directed by the Pharmacist.
  • I understand that there are possible adverse effects associated with administration of the below mentioned vaccine.
  • I understand that I may, at any time before, during or after the injection, ask the pharmacist further questions.
  • In the event of an emergency, I authorize the Pharmacist to administer epinephrine and/or perform any necessary lifesaving procedures until medical support arrives. In the case of an emergency, please contact:
Emergency Contact Name
Phone Number
  • I understand that I may experience symptoms following influenza immunization (i.e. Cough, Fever, etc) that are similar to symptoms that present with COVID-19 infection and am aware to contact my public health line if symptoms occur.
  • I understand that the Pharmacist will comply with all professional standards for administering injections. I acknowledge that the Pharmacist has discussed the risks and benefits of receiving this injection with me and has answered my questions.