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Influenza Vaccine Consent Form
Client's Name
(Required)
First
Last
Date of Birth
(Required)
Client is
(Required)
Self
Child
Other
Insurance
Has private insurance
Has HUSKY/Medicaid
Has no insurance
Is Native American or Alaskan Native
Parent/Guardian Name
(Required)
First
Last
Parent Guardian Phone Number
(Required)
School Client Attends
(Required)
Grade/Teacher
(Required)
Please select one of the following
(Required)
I would like to be present for my child’s flu vaccine. Please call me to schedule an appointment for my child’s flu vaccine.
I do not want to be present for my child’s flu vaccine. Please schedule their appointment during the school day without a parent/legal guardian present.
Does the patient have asthma or had wheezing in the last 12 months?
(Required)
Yes
No
Is the patient allergic to eggs?
(Required)
Yes
No
Has patient ever had Guillain-Barre syndrome?
(Required)
Yes
No
Is there anyone in the patient's household who has a poor immune system?
(Required)
Yes
No
Has patient ever had a flu shot before?
(Required)
Yes
No*
*If patient is less than 9 years old and never had a flu vaccine, 2 doses are needed a month apart.
Has patient ever had a bad reaction to a flu shot?
(Required)
Yes
No
Injection consent (child)
(Required)
I would like my child to receive
the injectable/shot (inactivated)
flu vaccine
I would like my child to receive
the nasal spray (live)
flu vaccine
Click here to review the Influenza (Flu) Vaccine (Live, Intranasal) information statement.
Click here to review the Influenza (Flu) Vaccine (Inactivated or Recombinant) information statement.
Vaccine Information Statement (VIS) Acknowledgement
I have read or have had explained to me the information about the influenza vaccine from the attached VIS. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the influenza vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request.
Patient or Parent/Guardian Signature
Client Signature
(Required)
Signature Date
(Required)
