hereby consent to the injection of seasonal influenza vaccine,2022 2023 type flu strain for
I release Smita P Mengers, MD and Dr Wendy VanBronkhorst, MD from any possible medical complications related to receiving the lnfluenza vaccine this date.
I understand that adverse reactions are frequent and usually mild, but they may occur. The most serious complication could be GUILLIAM-BARR SYNDROME (GBS). ln 1976 flu vaccine was associated with GBS, lnfluenza vaccine since then have not been clearly linked to GBs. However, if there is a risk of GBS from current influenza vaccines, it is estimated at 1-2 cases per million persons vaccinated.
I hereby that I have had the opportunity to review the CDC s 2022-2023 VIS and answered the CDC screening questionnaire before receiving the vaccine.
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I understand that my insurance company may not cover the flu vaccine and I will be responsible for the balance in full.
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