Flu Shot (Influenza) Vaccine Consent Form 3
Flu Shot (Influenza) Vaccine Consent Form 1
Flu Shot (Influenza) Vaccine Consent Form 2
Flu Shot (Influenza) Vaccine Consent Form 3
Flu Shot (Influenza) Vaccine Consent Form 1

Flu Shot (Influenza) Vaccine Consent Form

    Administering vaccines is a routine part of a healthcare provider’s work. To ensure a hassle-free immunization process, we’ve designed a flu shot vaccine consent form. The form contains all required details such as the full name of the person being vaccinated and the healthcare administrator. Provide vaccines easily by downloading our free flu shot vaccine consent form below.

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Flu Shot (Influenza) Vaccine Consent Form
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Flu Shot (Influenza) Vaccine Consent Form

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A vaccine consent form is quite important when it comes to the vaccination process at a healthcare organisation. Here you can find the vaccine consent form template that you can download and use directly.

All licensed medical practitioners use a vaccine consent form to remain protected against unfair lawsuits. In order to read more about vaccine consent form and when it is crucial to use it, keep reading the information below:

What Is a Flu Shot Vaccine Consent Form?

A flu shot vaccine consent form gives a nurse or a doctor the permission to go ahead and administer the patient with the flu vaccine.

This form is signed by the person who is going to be vaccinated. In case the person to be vaccinated is a minor, the consent form should be signed by the parents or the guardian.

Get a Standardized Flu Shot Vaccine Consent Form Below!

As per the law, healthcare administrators must receive informed consent from the person they are vaccinating to administer a shot. Instead of designing a new form for every patient, you can download our standardized flu shot vaccine consent forms below.

What Are Included in a Flu Shot Vaccine Consent Form?

The flu shot vaccine consent form contains the full name of the person who is to be vaccinated, along with the details of the healthcare administrator.

Through the form, the person consents to the fact that they are agreeing to the flu shot vaccine and they understand the possible side effects of the same.

The flu shot vaccine consent form also contains some questions to make sure that any person who might be at risk from the vaccine can avoid it, and it protects the healthcare administrator from any unforeseeable accidents that are not caused by intention.

It is best to use the flu shot vaccine consent form along with a detailed conversation with the person to explain to them the possible allergic reactions to the vaccine.

Get a Standardized Flu Shot Vaccine Consent Form Below!

As per the law, healthcare administrators must receive informed consent from the person they are vaccinating to administer a shot. Instead of designing a new form for every patient, you can download our standardized flu shot vaccine consent forms below.

Endnotes

Vaccine consent forms are very important to protect medical practitioners from any lawsuits that aren’t because of their fault. In order to create a vaccine consent form, all that is needed is to download the vaccine consent form template from CocoSign.

CocoSign offers various form templates ready to download with a single click. These templates can also be edited to include any additional requirements that you might have.

DOCUMENT PREVIEW

CONSENT FORM FOR SEASONAL INFLUENZA (FLU) VACCINE

I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice before coming

here today. I have had a chance 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 MY CHILD.


Please print:

 

Title:   Name:                              Last 4 SSN:           (FIRST)              (MIDDLE)              (LAST)

 

Child’s Birthday   /  /         & Age  (if applicable)

 

Is your child 6 months of age or older? YES NO (If “no,” your child may not receive the vaccine at this time.)

 

Parent or Guardian’s Name:                                         

 

Vaccine is for (check one):    Physician    Contractor  Employee  Volunteer Family Member (Adult)

  Family Member (Child)  Other                                        

Company/Organization:                               

 

Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers? YES NO

 

 

 

Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness?

YES NO

Has the person received a live vaccine within the past 30 days (i.e. MMR, RotaTeq/Rotarix)? Yes*  No

*If YES, it is recommended to space live vaccines by > 4 weeks for full efficacy

Is the person receiving the vaccine pregnant? YES NO

Is the person receiving the vaccine allergic to Neomycin, Thimerosal (Preservative found in contact lens solution), any vaccine ingredient, or latex? YES NO

For children 6 mo-8 yrs:  Have they received 2 or more doses of influenza vaccine since July 2015? YES NO

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

 

For children and adolescents aged 2-17 yrs:  Is the child taking long-term aspirin or aspirin-containing therapy?

YES NO

 



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:  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

  0.5mL Intradermal Virus Vaccine site        - TIV

  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 years:  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/ Provider’s Signature Date Time

 

 

 

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