Flu Vaccine Consent

Date

Child’s age:

Insurance Company Name:

I, (parent’s name)

hereby consent to the injection of seasonal influenza vaccine,2022 2023 type flu strain for

(child’s name)

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.

PLEASE SELECT YOUR ANSWER

1. ls the first time that your child is receiving the flu vaccine?

YES NO

2. ls your child allergic to eggs, egg products, gelatin, MSG, gentamicin or arginine?

YES NO

3. Did your child had a serious reaction to the flu vaccine in the past?

YES NO

4. Has the person to be vaccinated ever had Guillain-Barre syndrome?

YES NO

I understand that my insurance company may not cover the flu vaccine and I will be responsible for the balance in full.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent Signature:

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