Influenza Vaccine Consent Form

Combines patient demographics, insurance coverage details and the clinical screening that comes before a flu shot. The screening questions cover fever, allergies, past reactions, neurological history, recent vaccines, age and pregnancy. The patient accepts the terms and signs in the same submission. Aimed at clinics, pharmacies and community immunisation programmes.

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Patient name

Nombre

Apellido

Date of birth

Phone number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Gender

Female Male Other Prefer not to say

Ethnicity

Hispanic or Latino Not Hispanic or Latino Prefer not to say

Race

White Black or of African descent Asian Indigenous or Native Pacific Islander Mixed or more than one origin Prefer not to say

Primary doctor's name

Nombre

Apellido

Preferred clinic or hospital

Preferred pharmacy

I am interested in the following vaccinations

Influenza vaccine COVID-19 vaccine Pneumococcal vaccine Tetanus vaccine Shingles vaccine Hepatitis B vaccine

Insurance information

Public insurance Commercial insurance Employer plan No insurance

Public insurance details

Nombre

Apellido

Commercial insurance details

Nombre

Apellido

Insured patients

Bill my insurance directly I will pay the copay at the visit I have already provided my coverage card

Uninsured patients

I will pay out of pocket I am applying for the assistance programme My employer is covering it

Section

Does the person being vaccinated have a fever or illness today?

Yes No Not sure

Does the person have an allergy to eggs, latex or a vaccine component?

Yes No Not sure

Has the person ever had a serious reaction to this vaccine?

Yes No Not sure

Has the person had Guillain-Barré syndrome within 6 weeks of a vaccination, uncontrolled seizures or an unstable neurological disorder?

Yes No Not sure

Has the person received any vaccine in the past 30 days?

Yes No Not sure

Is the person being vaccinated 6 years of age or older?

Yes No Not sure

Is the person pregnant, breastfeeding or planning to become pregnant in the next 30 days?

Yes No Not applicable

Section

As the undersigned, I agree to the following

I have read the vaccine information sheet All my questions have been answered I consent to receiving the vaccine I authorise billing to my coverage I authorise sharing the record with my doctor

Date

Signature

Sign here

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