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Microsoft word - flu_vaccination_consent_form.odt

8640 East CR 466,
628 Hwy 27N
8972 Turkey Lake Road South
The Villages, FL
Clermont, FL 34714
Orlando, FL 32819
P- (352) 674-9218
P- (352) 242-1988
P- (407) 226-1906
F- (352) 259-6069
F- (352) 242-0866
F- (407) 226-1910

NAME………………………………………………………………………………………………………………
DATE OF BIRTH………………………………………………………………………………………………….
As the flu vaccine does not contain a live virus, it cannot give you the flu. Most people have no
unpleasant reaction to the vaccine.

Before agreeing to receive the flu vaccine, please:
• Take time to answer the following questions.
• If you have any questions, talk to your doctor or the person administering your shot. The information you
provide is private and confidential and will not be used for any other purpose.
• If you have any major medical conditions, please discuss and obtain advice from your treating provider.
1 Have you previously been vaccinated against the flu?
2 Did you experience any significant problems after previous flu vaccinations?
3 Are you ill at the moment? Do you have a fever?
4 Are you allergic to eggs, chicken feathers or any egg products?
5 Do you suffer from any other allergic reaction?
6 Are you taking any medications? (Please circle) cortisone, steroid,
dilantin (phenytoin sodium), immunosuppressive medication, warfarin,
treatment for seizures/fits?
7 Are you pregnant or breastfeeding?

After your flu shot.
• The flu vaccine is generally well-tolerated.
• Like all medicines, vaccines may have side-effects. Some redness, tenderness, discomfort or swelling is
common at the injection site, but this usually settles within a few days.
• Some people have a slight fever, muscle pains and generally feel a bit unwell for a few days after vaccination.
These 'flu-like symptoms' do not mean they have the flu.
I have read and understand this information. I consent to receiving a flu vaccine injection.
SIGNATURE………….…………………………………………………………………………………………
DATE……………………………………………………………………………………………………….

FLU VACCINE GIVEN BY……………………………………………………………… INJECTION GIVEN
BATCH NUMBER……………………….……………………………EXP……………… FLUZONE / AFLURIA / FLUVIRIN
SIGNATURE………………………….…………….DATE………………………. (Q2038 / Q2035 / Q2037)

Source: http://paramounturgentcare.com/wp-content/uploads/2011/06/Flu_Vaccination_Consent_Form.pdf

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