Seasonal Influenza Vaccine Form PDF Details

The Seasonal Influenza Vaccine Consent Form is a critical document that ensures individuals are informed and agree to receive the flu vaccine under safe and understood circumstances. It starts with a declaration that the recipient has been informed about the influenza vaccine, including its benefits and risks, and has had the opportunity to ask questions. This is a testament to the informed consent process, crucial in healthcare settings. Key personal information such as name, ID or social security number, and date of birth is required, alongside specifying the recipient's role, such as a student or healthcare provider, and the location of work or study. The form takes into account personal health considerations by inquiring about allergies, Guillain-Barré syndrome, or pregnancy, ensuring the vaccine’s suitability for each individual. Choices of vaccine administration are outlined, including dosages for different age groups and injection methods. The requirement for the recipient's signature alongside the date affirms their consent, whereas the latter section of the form reserved for office use documents the vaccine's specifics—type, lot number, and expiration date. This process not only serves as a medical record but also supports transparency and trust between healthcare providers and vaccine recipients.

QuestionAnswer
Form NameSeasonal Influenza Vaccine Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesvaccine consent form north las vegas, influenza vaccine form pdf, influenza vaccine consent form, flu shot consent form

Form Preview Example

CONSENT FORM FOR SEASONAL INFLUENZA 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.

Please print clearly: Each field is required.

Name: ________________________________________________ 3/4 ID or Last 4 SSN: _________________

(FIRST)

(MIDDLE)

(LAST)

 

 

 

Birthday____/____/____

 

 

 

 

 

Vaccine is for (circle one): Student

Physician

Licensed HCP

Contractor

Volunteer

Working in which facility?: _________________________________________________

 

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

Is the person receiving the vaccine pregnant? ____Yes

____No (If yes, LAIV contraindicated, TIV recommended)

Is the person receiving the vaccine allergic to Thimerosal (Preservative found in contact lens solution), any

vaccine ingredient, or latex? ____Yes

____No

 

 

 

 

 

 

X________________________________________________________________ ______________________

Signature of person receiving vaccine

 

 

 

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

 

 

___ 0.2 mL Live Attenuated Influenza Virus Vaccine given intranasally (half each nostril) – TRI or QUAD

___ 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

How to Edit Seasonal Influenza Vaccine Form Online for Free

The whole process of completing the influenza vaccine consent form is very effortless. Our team ensured our PDF editor is not difficult to work with and helps fill in any sort of form within minutes. Listed below are some of the steps you will need to take:

Step 1: Press the orange button "Get Form Here" on this web page.

Step 2: Right now, it is possible to edit your influenza vaccine consent form. This multifunctional toolbar makes it possible to include, eliminate, modify, highlight, and perform many other commands to the text and fields within the document.

The following areas will frame the PDF document that you will be completing:

example of blanks in flu shot consent form

In the Signature of person receiving, Date, DO NOT WRITE IN THIS SPACEOFFICE, Lot number Expiration Date, CHECK ONE, mL IM Influenza Virus Vaccine, Nurse Providers Signature, Date, and Time area, put in writing your data.

flu shot consent form Signature of person receiving, Date, DO NOT WRITE IN THIS SPACEOFFICE, Lot number Expiration Date, CHECK ONE, mL IM Influenza Virus Vaccine, Nurse Providers Signature, Date, and Time fields to fill

Step 3: When you hit the Done button, the ready document is readily exportable to any type of of your devices. Alternatively, it is possible to deliver it via email.

Step 4: To avoid any hassles as time goes on, be sure to create a minimum of a couple of copies of the document.

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