Flu Consent Form

Vaccine Name:
Influenza Vaccine (inactivated) Trivalent Prese. Free .5mL

Vaccine Manufacturer:
Sanofi Pasteur

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.

Signature & title of vaccine administrator

For patients (both children and adults) to be vaccinated: the following questions will help us determine if there is any reason, we should not give you or your child and activated injectable influenza vaccine today. If you answer “yes” to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your health care provider to explain it.

1. Is the person to be vaccinated sick today?

Yes No Don't Know

2. Does the person to be vaccinated have any allergies to the flu vaccine or to the component of the vaccine?

Yes No Don't Know

3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?

Yes No Don't Know

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

Yes No Don't Know

I have had a chance to ask questions on behalf of my child. Any questions were addressed to my satisfaction. I believe I understand the benefits and risks of influenza vaccine and ask that the vaccine be given to me and to my child.

Signature of parent or legal guardian

Date

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