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________________________