Flu Vaccine Consent

FLU VACCINE CONSENT

Above is the printable PDF

FLU VACCINE CONSENT

I have read or had explained to me information about the flu vaccine. I understand the benefits and risks of the vaccine and ask that the vaccine be given to my child,_____________________________,

(NAME)

Date of birth_________________, for whom I am authorized to give consent.

CHOOSE ONE:

____FLU SHOT, INACTIVATED

____FLUMIST, LIVE (if available)

CHECK IF TRUE:

____MY CHILD HAS BEEN FEVER-FREE FOR PAST 24 HOURS

____MY CHILD HAS NOT HAD A POSITIVE COVID TEST IN THE PAST 14 DAYS

____MY CHILD DOES NOT CURRENTLY HAVE A COVID TEST PENDING

___________________________________________ ___________________________

SIGNATURE RELATIONSHIP TO PATIENT

DATE_______________________________________

_________________________________________________________________________________

FOR OFFICE USE ONLY

Manufacturer ________________

Lot number__________________

Site________________________

Initials______________________

Date________________________