INFLUENZA VACCINE (INFLUVAC) CONSENT FORM

I have read and fully understand the information explained to me regarding the influenza vaccine. I have had an opportunity to
discuss the benefits and risks of influenza vaccine with a health care provider of my choice before coming here today.

Title: Name: Age: Gender:

Date of Birth:
Current Medication: If any:
Contact Number:
School: Designation:

Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken
feathers? ☐ YES ☐ NO

Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness?
☐ YES ☐ NO
Is the person receiving the vaccine pregnant? ☐ YES ☐ NO

Is the person receiving the vaccine allergic to Neomycin, Thimerosal (Preservative found in contact lens solution), any vaccine
ingredient, or latex? ☐ YES ☐ NO

Acknowledgement:
1. I am at least 18 years of age, I was properly informed and oriented regarding the Influenza Vaccine that I will be receiving today
on what are the things I need to know, how it works and after care. I have been given the opportunity to ask the Health care
professional concerning the Influenza vaccine. All my questions regarding the vaccine have been answered to my satisfaction. I
understand the benefits and risk of the influenza vaccine and request that it will be given to me.
2. I affirm that I am not allergic to eggs, chicken, albumin products or a previous dose of influenza vaccine.
3. I do not have History of Guillain-Barré syndrome. (Rare auto immune system disorder which is actually a weakness and tingling
sensation

Release of Liability:
I have read and I understand the acknowledgement set forth above, and I hereby release the provider entities signed under
this consent and all of their affiliates from any and all liabilities which may arise from the vaccination and/or from the information
provided to me concerning such vaccination.

Consent to the vaccination:

I have read and understand the information set forth in this form. Based on the understanding that, I hereby signed the
CONSENT to Influenza Vaccine, (INFLUVAC) given to me.

Signature of person receiving vaccine OR Parent/Guardian Date

Nurse Name and Signature Date Time

Physican or Provider’s Signature Date Time