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Influenza Vaccine Consent Form
Patient's Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Primary Care Provider
(Required)
Patient is
(Required)
Self
Child
Child's School
(Required)
School Grade
(Required)
Parent/Guardian Name
(Required)
First
Last
Parent Guardian Phone Number
(Required)
I want my child's school-based health center to give my child the flu vaccine
(Required)
Yes
No
If you would like to be present for your child’s vaccine, please call 860-437-4550 to set an appointment. Otherwise, a time will be set to give the vaccine during the school day without a parent present.
Vaccines are available by appointment only. Please call 860-437-4550 to schedule an appointment with our CFA Medical Clinic located at 7 Vauxhall Street, New London, Connecticut.
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
Injection consent (self)
(Required)
I would like to receive
the injectable/shot (inactivated)
flu vaccine
I would like to receive
the nasal spray (live)
flu vaccine
Patient has (check one)
(Required)
has private insurance
has HUSKY/Medicaid
has no insurance
is Native American or Alaskan Native
Health Questions
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
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 vaccine visit.
I do not want to be present for my child’s flu vaccine. Please schedule their appointment during the school day without a parent/guardian present
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.
VIS Acknowledgement
I have read or have had explained to me the information about the influenza vaccine from the attached Vaccine Information Statement (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.
For CFA Medical Clinic Visits:
I give permission for my insurance to be billed at time of visit. I understand that a sliding scale will be available for those without insurance. I authorize the release of any medical information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency of Southeastern CT, Inc. for services provided. I understand and acknowledge that I have read and understand this consent.
Patient or Parent/Guardian Signature
(Required)
Relationship to Patient (If <18 years of age):
Signature Date
(Required)
MM slash DD slash YYYY
