Generic Flu Shot Consent Form
INFLUENZA VACCINE (FLU SHOT) CONSENT FORM 1. Have you ever had an allergic reaction to flu vaccine? Yes or No 2. Are you allergic to eggs or egg products?
Flu Shot Consent Form Please circle your response 1. Have you had a flu shot before? Yes No 2. Are you allergic to eggs? Yes No 3. Are you currently taking an antibiotic for infection?
INFLUENZA VACCINE (FLU SHOT) CONSENT FORM 2009-2010 A/Brisbane/59/2007 (H1N1)-like virus — A/Brisbane/10/2007 (H3N2)-like virus — B/Brisbane/60/2008-like virus 1.
2011 Injectable Influenza Vaccine Consent Form SECTION 1: INFORMATION ABOUT PERSON RECEIVING VACCINE (PLEASE PRINT " CLEARLY ") NAME (Last) ... named above ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine? SECTION 3: CONSENT FOR ...
... 2Have you been sick in the past two weeks? 3Are you allergic to chicken, eggs, or egg products? 4Have you ever had an allergic reaction to a flu shot? ... Date Given Exp. Date RouteAdministered By: RD RT LD LT FOR OFFICE USE ONLY Manufacturer & Lot No. Site (circle) Flu Vaccine Consent Form CONSENT AND RELEASE ...
2010-2011 Corporate Vaccination Consent & Release 1. Decide if you would like the 'flu shot' or the Intranasal Flu Mist and circle your choice below - review the Vaccine Information Sheets for details on both vaccines 2.
Influenza Vaccine Consent Form 2010 - 2011 (Last Name) (First Name) (MI) Date of ... Acute allergic reaction – high fever, confusion, difficulty breathing, hives, rapid heartbeat – would occur within a few minutes of the shot.
INFLUENZA (FLU) VACCINE Informed Consent Form Flu Influenza (flu) is a respiratory disease caused by influenza virus infection. The types or strains of influenza virus causing illness may change from year to year, or even within the same year.
Time in:_____ Influenza Documentation Consent Form Time ... Syndrome within 6 weeks after a previous flu shot? __Yes __No 6. Are you taking cortisone, prednisone, other steroids, anti-cancer drugs or receiving radiation treatments?
VACCINE DOCUMENTATION/CONSENT FORM I have been offered a copy of the Vaccine Information Statement(s) (VIS) checked below. I have read, had explained to me, and understand the information in the VIS(s).
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