Flu Vaccine Consent Form

Collects patient authorization together with a complete medical screening before administering the influenza vaccine. It covers personal details, reaction history and relevant health conditions, and closes with the consent signature.

Use this template

Full Name

Nombre

Apellido

Phone Number

Date of Birth

Today's Date

Gender

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Name of Your Doctor

Nombre

Apellido

Doctor's Address

Dirección

Ciudad

Estado / Provincia

Código postal

Vaccine to Be Administered

Standard quadrivalent High-dose (seniors) Adjuvanted Egg-free Nasal spray

Are you feeling sick today?

Yes No Don't know

Do you have any health conditions, such as heart disease, diabetes or asthma?

Yes No Don't know

Please indicate your health conditions below

Do you have an allergic reaction to medications, food, or any vaccine ingredients (aluminum, eggs, gelatin, neomycin, latex, thimerosal, preservatives, etc.)?

Yes No Don't know

Please indicate below

Have you ever had a serious reaction after receiving a vaccination, such as fainting or feeling dizzy?

Yes No Don't know

Have you ever had seizures, a brain disorder, Guillain-Barré syndrome or another nervous system problem?

Yes No Don't know

Have you received any vaccinations or skin tests in the past 4-8 weeks?

Yes No Don't know

Please list below

Are you currently on home infusions, weekly injections, anticancer drugs or radiation treatments?

Yes No Don't know

Are you currently taking high-dose steroid therapy for longer than 2 weeks?

Yes No Don't know

Have you received a transfusion of blood or blood products, or the medication immune (gamma) globulin, in the past year?

Yes No Don't know

Have you had yellow fever?

Yes No Don't know

Do you have a history of thymus disease or had your thymus removed?

Yes No Don't know

Do you have a history of thrombocytopenia or thrombocytopenic purpura?

Yes No Don't know

Have you consumed any food or drink in the last hour?

Yes No Don't know

Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days?

Yes No Don't know

Are you pregnant or planning to become pregnant in the next 30 days?

Yes No Not applicable

Has your child had wheezing or asthma in the past 12 months?

Yes No Not applicable

Have you had a shingles vaccination or been diagnosed with shingles in the last 12 months?

Yes No Don't know

Have you ever had a pneumococcal vaccination?

Yes No Don't know

Consent statement: I have read the vaccine information, had the chance to ask questions, and voluntarily agree to receive the vaccine.

Age of Consent

I am 18 or older and consent for myself I am under 18 and my legal guardian consents I am the legal guardian consenting on the patient's behalf

Full Name

Nombre

Apellido

Date

Signature

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