Flu vaccine form 2019 printable
[PDF File]Influenza/Pneumococcal Immunization Consent Form
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Influenza/Pneumococcal Immunization Consent Form Influenza Consent I have read,or hadexplainedto me, the Vaccine Information Statement about influenza vaccination. I have hada chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described.I request that the influenza vaccination be given to me (or the person named above ...
[PDF File]HEALTH CARE PROVIDER INFLUENZA VACCINE CONSENT …
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VACCINE CONSENT FORM 2019-2020 clinic stamp Last name: ... vaccine, is this the first or second dose of seasonal influenza vaccine this year? First Second If second, please indicate the date of the first dose: _____/_____/____ (year, month, day) Are you feeling ill today? No Yes If yes, please explain below Have you ever had an allergic reaction to a vaccine? No Yes If yes, please explain ...
[PDF File]Vaccine Information Statement: Inactivated Influenza Vaccine
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Influenza vaccine does not cause flu. Influenza vaccine may be given at the same time as other vaccines. 3 Talk with your health care provider Tell your vaccine provider if the person getting the vaccine: Has had an allergic reaction after a previous dose of influenza vaccine, or …
[PDF File]2019-2020 INFLUENZA VACCINE DECLINATION FORM
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2019-2020 INFLUENZA VACCINE DECLINATION FORM PRINT NAME: _____ DOB: _____ I DO NOT WANT A FLU SHOT I acknowledge that I am aware of the following facts: • Influenza is a serious respiratory disease; on average, 36,000 Americans die every year from influenza-related causes.
[PDF File]CONSENT FORM FOR SEASONAL INFLUENZA VACCINE
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CONSENT FORM FOR SEASONAL INFLUENZA VACCINE . I have read or have had explained to me the information about influenza and influenza vaccine. 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. I have had a chance to ask questions which were answered ...
[PDF File]2018-2019 INFLUENZA VACCINE - ADMINISTRATION RECORD
https://info.5y1.org/flu-vaccine-form-2019-printable_1_043d14.html
This form helps us to decide which vaccines should be given in the pharmacy today. Please answer the following questions. 1. Did you receive a flu vaccine last year? Yes or No 2. Are you sick today? Yes or No (If you are currently sick enough to go to the doctor or emergency room, you should postpone receiving a flu vaccine.) 3. Do you have ...
[PDF File]2018-2019 Seasonal Flu Shot (IIV*) Vaccine Consent Form
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2018-2019 Seasonal Flu Shot (IIV*) Vaccine Consent Form Sign your child up for a no-cost vaccination offered during school hours. You can also sign up online at nassauflu.com
[PDF File]2019 Influenza Immunisation Consent Form
https://info.5y1.org/flu-vaccine-form-2019-printable_1_72f5ec.html
2019 Influenza Immunisation Consent Form Name: Date of Birth: ... Have you previously been vaccinated against the flu? Yes No 3. Have you experienced any significant problems after vaccination? Yes No 4. Are you allergic to eggs or chicken feathers? Yes No 5. Are you allergic to neomycin, or latex? Yes No 6. Are you taking any cortisone, steroid, immunosuppressive medication or theophylline ...
[PDF File]PLEASE PRINT! Seasonal Flu Vaccine Consent Form
https://info.5y1.org/flu-vaccine-form-2019-printable_1_9b429b.html
immune or that I will not experience side effects. I understand that I should not receive the flu vaccine if I have ever had a life-threatening allergic reaction to a previous influenza vaccine, or have a severe allergy to any part of this vaccine or if I have ever had Guillain -Barré Syndrome (a …
[PDF File]Flu Vaccine Form - McElroy Pharmacy
https://info.5y1.org/flu-vaccine-form-2019-printable_1_5dbd47.html
I, the undersigned, have read or had explained to me the vaccine information sheet (VIS). I understand the risks and benefits associated with the influenza vaccine and have had any questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the aforementioned person for whom I am authorized to make this request.
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