Influenza, more colloquially known as the flu, is a highly contagious respiratory illness caused by the influenza virus. Each year, millions of people are infected with the flu, and thousands die from it. Seasonal flu vaccinations are available to protect individuals from becoming infected with the flu virus. In this blog post, we will discuss the different types of seasonal influenza vaccine forms available and how to get vaccinated.
You'll discover info about the type of form you need to prepare in the table. It can tell you how long it may need to finish seasonal influenza vaccine form, exactly what fields you will need to fill in, etc.
| Question | Answer |
|---|---|
| Form Name | Seasonal Influenza Vaccine Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | immunization consent form pdf, vaccine consent form north las vegas, informed consent form flu vaccine, what form is provided before taking the vaccine |
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) |
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Birthday____/____/____ |
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Vaccine is for (circle one): Student |
Physician |
Licensed HCP |
Contractor |
Volunteer |
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Working in which facility?: _________________________________________________ |
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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
Is the person receiving the vaccine pregnant? ____Yes |
____No (If yes, LAIV contraindicated, TIV recommended) |
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Is the person receiving the vaccine allergic to Thimerosal (Preservative found in contact lens solution), any |
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vaccine ingredient, or latex? ____Yes |
____No |
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X________________________________________________________________ ______________________ |
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Signature of person receiving vaccine |
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Date |
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DO NOT WRITE IN THIS |
VIS Edition Provided: ________________ |
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Lot number: ________________________Expiration Date: ____________________ |
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CHECK ONE: |
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___ 0.5 mL IM Influenza Virus Vaccine given in ___left |
___right deltoid – TIV or QIV |
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___ 0.5 mL IM Influenza HIGH Dose Virus Vaccine given in |
___left ___right deltoid (65+) |
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___ 0.2 mL Live Attenuated Influenza Virus Vaccine given intranasally (half each nostril) – TRI or QUAD |
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___ 0.5mL Intradermal Virus Vaccine |
site ________________________ - TIV |
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___ 0.5mL FluBlok Influenza Virus Vaccine given in ___left |
___right deltoid |
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___ Children |
___right deltoid (1 or 2 doses per season) |
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___ Children |
___right deltoid (1 or 2 doses per season) |
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___ Children older than 9 years: 0.5 mL/dose given in |
___left ___right |
deltoid (1 dose per season) |
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_________________________________________________________ |
__________________ |
_________ |
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Nurse/ Provider’s Signature |
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Date |
Time |
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