INFLUENZA VACCINE CONSENT FORM

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

Last Name

First Name

Gender

Male Female

Date of Birth

Phone

Your Email

PHN

Address

City/Town

Postal Code

* Please answer all questions

Have you ever had a influenza vaccine before?

Do you have a fever or feel sick today?

Have you ever had a reaction to the flu vaccine (i.e.: hives, difficulty breathing)?

Please Specify The Symptoms

Have you ever had Guillain-Barre Syndrome (GBS), a disease that causes your muscles to stop working? Guillain-Barre (gee-YAH-buh-RAY) syndrome is a rare disorder in which your body's immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms.

Are you allergic to: Thimerosal (mercury) Thimerosal is a mercury-based preservative that has been used for decades in the United States in multi-dose vials (vials containing more than one dose) of medicines and vaccines to prevent growth of germs, like bacteria and fungi. Introduction of bacteria and fungi has the potential to occur when a syringe needle enters a vial as a vaccine is being prepared for administration. Contamination by germs in a vaccine could cause severe local reactions, serious illness or death.

Are you allergic to: Neomycin

Are you allergic to: Gentamicin

Are you allergic to: Kanamycin

Are you allergic to: Formaldehyde

Are you allergic to: eggs / egg products (severe allergy such as hives, difficulty breathing etc.)

Do you have a bleeding disorder (i.e.: hemophilia)?

Do you take blood thinners (i.e.: aspirin, coumadin, warfarin)?

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).

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.

Signature

Uploaded Sign Images