Seasonal Influenza Vaccine Form PDF Details

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.

QuestionAnswer
Form NameSeasonal Influenza Vaccine Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesimmunization consent form pdf, vaccine consent form north las vegas, informed consent form flu vaccine, what form is provided before taking the vaccine

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

Watch Seasonal Influenza Vaccine Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .