Flu Shot (Influenza) Vaccine Consent Form
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CONSENT FORM FOR SEASONAL INFLUENZA (FLU) VACCINE
I have read or have had explained to me the information about influenza and influenza vaccine. I have had an
opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice before coming
here today. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and
risks of influenza vaccine and request that the vaccine be given to ☐ ME ☐ MY CHILD.
Please print:
Title: _____ Name: ________________________________________________ Last 4 SSN: ______________
(FIRST)
(MIDDLE)
(LAST)
Child’s Birthday____/____/____ & Age__________ (if applicable)
Is your child 6 months of age or older? ☐ YES ☐ NO (If “no,” your child may not receive the vaccine at this time.)
Parent or Guardian’s Name: ___________________________________________________________________
Vaccine is for (check one): ☐ Physician ☐ Contractor ☐ Employee ☐ Volunteer ☐ Family Member (Adult)
☐ Family M