Flu Vaccine Consent Form 2020 2021, Lee Middle And High School Flu Clinic For Lmhs Students

Patient full name address emergency contact emergency contact phone number physician nurse practitioner physiciannp phone number 2.

Whooping cough vaccine for adults walgreens. Extremely rare allergic reactions ranging from hives to death. Yes no 2. Client information clients last name.

The vaccine contains no live virus so it cannot cause the flu. Have you ever previously been vaccinated against the flu. Have you ever had a severe reaction to the flu vaccine.

A flu shot influenza vaccine consent form is a written authorization that gives a nurse or other medical practitioner the go ahead to administer the flu vaccine. Most common soreness at the vaccine site 2. Seasonal influenza vaccine consent form 2020 2021 print name.

Annual influenza vaccine consent form flu shot. Consent form 2020 quadrivalent influenza vaccine medical history please answer the medical history questions below. Have you experienced any significant problems after previous flu vaccinations.

2020 2021 seasonal influenza flu vaccine consent form. Consent for flu vaccine. Yes no 3.

Yes no 1. Date of birth. The choice of which consent forms to distribute to parentsguardians will depend on which vaccine formulation live attenuated intranasal vaccine laiv inactivated injectable vaccine or both will be offered at the slv clinic.

Are you currently ill and have fever greater than 101 degrees. Date of birth. Manufacturer and lot number flu vaccine vis iiv 08152019 inactivated flu shot iiv gsk sp lot example 10202019 please print clearly date administered mmddyyyy admin initials.

Rare fever bodyache usually gone in two days 3. Please attach a copy of the completed flu consent form to be compliant with the. You are receiving the 2020 2021 influenza flu vaccine.

This form includes a series of questions that can help to exclude patients who are at risk for complications and those who otherwise. Health card number date of birth mmddyyyy phone number xxx xxx xxxx parentguardian name if under 16 first. Understand the information contained on this form may be disclosed to the public health authority and to other required parties for the purpose of adverse event and.

Are you allergic to eggs. Covid screening and health information. 2020 2021 influenza vaccine consent form 1.

Los angeles county health agency acknowledgement of receipt notice of privacy practices effective date. 20202021 influenza vaccine consent form. It should be signed by the patient or in the case of a minor by a parent or legal guardian.

Clients first name. Flu vaccine consent form screening questionnaire and consent form for influenza vaccine 2020 2021 indicates required field. Patient name first.