Flu Vaccine Consent Form 2024-2025

Flu Vaccine Consent Form 2024-2025 – I consent to receiving the seasonal influenza vaccine. Imm.f.hcp flu consent form revised sept 2024. I understand the benefits and risks of the. Patient name phone # date of birth date.

Two influenza a viruses (h1n1 and h3n2) and one influenza b virus. I am aware that some people experience pain at the site of injection, and some may even experience fever. Physician's name insurance(s) please answer the following questions: I have been provided a copy of and have read or have had explained to me the information about influenza and influenza vaccine.

Flu Vaccine Consent Form 2024-2025

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Flu Vaccine Consent Form 2024-2025

Discussed possible side effects : You must remain in the clinic area 15 minutes after the vaccination is given. Information about influenza vaccine products available in the u.s.

Last name first name m id le inta building / work location. Qr code links to vaccine information statement (vis) translations: I have had a chance to ask questions that were answered to my satisfaction.

Yes no if yes, please ask for an employee health consent form. The information you provide to complete this form indicates you understand the benefits and risks of receiving the influenza vaccine, as indicated in the cdc’s vaccine information statement (vis), and are requesting to be vaccinated. Influenza (flu) vaccine (inactivated or recombinant).

I testify that i have none of the conditions listed below: A severe reaction to the flu shot in the past. If you have answered yes to any of the above questions, consult a physician prior to receiving the flu vaccine.

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