A flu shot influenza vaccine consent form is a written authorization that gives a nurse or other medical practitioner the goahead to administer the flu vaccine. But even if youre late, the cdc still recommends getting vaccinated. Vaccine administration record var informed consent for vaccination healthcare providers can be an immunizationcertified pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner, physician or physicians assistant. The best way to prevent the flu is by getting vaccinated each year. Screening checklist for contraindications to inactivated. Inactivated influenza vaccine consent and administration. Take advantage of each office visit as an opportunity to encourage patients to protect themselves from the flu and serious complications by getting a flu shot. Please contact customer service at 1800 vaccine 18008222463 with any questions regarding the return goods policy. I decline to receive seasonal influenza vaccine at this time for the following reason. Flu is a contagious disease that spreads around the. Influenza vaccine may be given at the same time as other vaccines.
Cumulative 20192020 season lot release status updated 7182019 flu vaccine lots that have been released by fda and are available for distribution by. Standing orders for administering influenza vaccine to adults. If yes to any questions then do not vaccinate with influenza vaccine. I acknowledge that i am aware of the following facts please read and check each box. Scanned copy of vaccination documentation that includes the details of the vaccination and the date given please submit scanned copy with form or 2. Return original to facility or person requesting form.
Health care personnel influenza vaccination form i am a va. Flu vaccination record keeping and data requirements in light of the general data protection regulations and to facilitate the expansion of the postpayment verification process to cover the flu vaccination service, the consent form and record form were separated into two different forms. I have read and understand the information i have received concerning the possible benefits and side effects of the influenza vaccination. Flu vaccination has been shown to prevent flu illnesses, doctors visits and hospitalizations and can be lifesaving in children. I further understand that if i have a condition of or am undergoing treatment which causes immunosuppression the reduction in my bodys ability to fight infection and illness, the effectiveness of the vaccine in preventing the flu may be diminished. Getting the flu vaccine as soon as it becomes available each year is best.
Flu vaccination record keeping and data requirements. 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. Enter your official identification and contact details. I, the undersigned, have read or had explained to me the vaccine information sheet vis. Nhs community pharmacy seasonal influenza vaccination. Start with a free immunization evaluation to see what vaccines you need. Continue to provide the flu shot if you have vaccine available, even after the new year. How you can fill out the flu vaccine form on the web. Screening checklist for contraindications to inactivated injectable influenza vaccination patient name date of birth for patients both children and adults to be vaccinated. The fotonovela is available in spanish and english bilingual.
I have read, or had explained to me, the vaccine information statement about influenza vaccination. Have you ever had an allergic reaction to flu vaccine. If any of the following apply to you then please advise your healthcare professional. Under the national childhood vaccine injury act ncvia, federal law requires that vis be handed. Each year a new flu vaccine is made to protect against three or four viruses that are likely to cause disease in the upcoming flu season. Seasonal influenza and pneumococcal prevention campaign educational materials order form pdf, 225kb educational posters and brochures. Live vaccines chickenpox, flu nasal spray, mmr ii, oral typhoid, shingles, yellow fever. Free flu shot influenza vaccine consent form pdf word.
Pdf stay healthy pdf ready wrigley prepares for flu season childrens activity book pdf. The centers for disease control and prevention cdc recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this serious disease. People 5 to 64 years of age with medical risk factors predisposing to severe influenza all aboriginal persons 5 to 64 years of age pregnant women available in singles and 10 packs give two doses one month apart for children aged 5 to less than 9 years if first year of receiving flu vaccine. Start a free trial now to save yourself time and money. The advanced tools of the editor will guide you through the editable pdf template. Flu shot consent form version 201112 information about patient receiving vaccination please print. Even when the vaccine doesnt exactly match these viruses, it may still provide some protection. Texas vaccines for children publications related to patient eligibility, screening, and referral. The fotonovela is a tool to help facilitate a discussion of the importance of influenza vaccination among pregnant women. I have read or have had explained to me the information about influenza and influenza vaccine. Influenza vaccine can be ordered online at the influenza vaccination provider toolkit has been developed to assist providers with managing rollout and implementation of their flu vaccination program in. Everyone 6 months and older needs a flu vaccine each year. The document ensures that the receiver of the vaccination is aware of the process and side effects, and that theyve had ample opportunity to field any questions they may have.
If you are experiencing a medical emergency, seek immediate assistance from a healthcare provider or call 911. Flu shot record form fill online, printable, fillable, blank pdffiller. The flu shot consent form must be completed before a influenza vaccine is administered. If you need individual medical or health care advice, consult a qualified healthcare provider. Documenting parental refusal to have their children. Seasonal influenza vaccination 2020 immunisation programs. If yes to question 4, vaccinate when resident has recovered. Take 3 steps to fight the flu pdf go ahead, ask me why i got my flu shot. The use of this or a similar form in concert with direct and non. Keep this article and refer to it throughout the 20192020 flu season. Cdc and fda do not provide individual medical treatment, advice, or diagnosis. Flu shot form fill out and sign printable pdf template.
Flu vaccine record form fill out and sign printable pdf template. It should be signed by the patient, or, in the case of a minor, by a parent or legal guardian. If the vaccine is refused due to this content, only children who are at high risk from flu due to a medical condition will be offered an alternative injected vaccine. Vaccine administration record var informed consent for. Under the programs dropdown box, select immunization and vaccines influenza flu, then press the go button. Guidance for medical exemptions for influenza vaccination can be obtained from the contraindications. I understand the risks and benefits associated with the influenza vaccine and have had any questions satisfactorily answered. Flu shot verification form this form verifies that the individual below received a flu vaccination from totalwellness. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller. Flu vaccine record form fill out and sign printable pdf.
Fill out, securely sign, print or email your flu vaccine record form instantly with signnow. Vaccine information statements vis are information sheets produced by the centers for disease control and prevention cdc that explain to vaccine recipients, their parents, or their legal representatives both the benefits and risks of a vaccine. The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable. I attach the following evidence that i have been vaccinated with a quadrivalent flu vaccine. If you will be participating in an international experience you may also be required to provide proof of vaccines such as yellow fever or typhoid. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. The the complete sanofi pasteur return goods policy can be viewed under the customer serv ice page on. Vaccination clinics should only be scheduled once vaccine has been received. Vaccine information statement inactivated influenza. I am currently unwell with a high fever i have had a previous severe response to an influenza vaccination. This flu shot consent form is designed to by given out by medical professionals and completed by patients agreeing to a. Click on an audience for products in different sizes, formats, and languages. The nasal flu vaccine contains products derived from pigs porcine gelatine.
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