Health.iu17.org



2019-2020 Influenza Vaccination Consent FormFirst Name:____________________________________ Last Name: ____________________________________Home Address:_______________________________________________________________________________City:___________________________________________________ State: ________ Zip: ___________________Phone Number:(___________)______________-___________________Date of Birth:______________/_________________/________________Last 4 Social Security #:____________________________________________Employer: ____________________________________________CONSENTI understand the benefits and risks of influenza vaccination as described in the Centers for Disease Control and Prevention (CDC) Flu Vaccine Information Sheet. I request that the vaccine be given to me or to the person for whom I am authorized to sign. I agree to release UPMC Susquehanna and its employees from any and all liability which might result from the administration of the vaccine, reactions to the vaccine or the composition or potency of the vaccine. I also acknowledge that no warranties, either implied or expressed, have been made with respect to the efficacy of the vaccine.Flu Vaccine is recommended for any woman who will be pregnant or breast feeding during the influenza season. The Flu Vaccine can be given in any trimester.Are you allergic to eggs or egg products? ?Yes?NoHave you had Guillain-Barre Syndrome with-in the last 6 weeks? ?Yes?NoHave you ever had an anaphylactic reaction to the influenza vaccine? ?Yes?NoDo you currently have a Primary Care Physician? ?Yes?NoI have received and/or reviewed the CDC Influenza Vaccine Information Sheet (08/15/19)? ?Yes?NoParticipant signature: _____________________________________ Date___________________Office Use OnlyFlu Vaccine Manufacturer: Seqirus Lot # Expiration Date: Site: ? Left Deltoid (IM) ? Right Deltoid (IM) Dose: 0.5 ml__________________________________________ ? RN ? LPN MA Date:_______________Signature of Administrator ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download