2024-2025 Flu Vaccine Consent Form

2024-2025 Flu Vaccine Consent Form – The 2024/2025 trivalent vaccine (tiv) protects against 3 different flu viruses: I have had a chance to ask questions that were answered to my satisfaction. I certify that i am the parent or legal guardian of this patient named above. (h1n1 and h3n2) and two influenza b viruses.

Patient name phone # date of birth date. Influenza (flu) vaccine (inactivated or recombinant): Information about child to receive vaccine (please print). I have been provided a copy of and have read or have had explained to me the information about influenza and influenza vaccine.

2024-2025 Flu Vaccine Consent Form

The information you provide to complete this form indicates you understand the benefits and risks of receiving the influenza vaccine, as indicated in the cdc's vaccine information statement (vis), and are requesting to be vaccinated. I consent to receiving the seasonal influenza vaccine. Yes no if yes, please ask for an employee health consent form.

Last name first name m id le inta building / work location. Last 4 digits of ssn date of birth. Williams, nicole l created date:

I am aware that some people experience pain at the site of injection, and some may even experience fever. Two influenza a viruses (h1n1 and h3n2) and one influenza b virus. I testify that i have none of the conditions listed below:

Imm.f.hcp flu consent form revised sept 2024. If you have answered yes to any of the above questions, consult a physician prior to receiving the flu vaccine. You must remain in the clinic area 15 minutes after the vaccination is given.

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