Www.garrisonvilleurgentcare.com
Garrisonville Urgent Care
9 Center Street
Suite 101
Stafford, VA 22556
[pic]
Telephone (540) 288-2222
Influenza Vaccine Registration/Consent Form
1. Name:______________________________________________________Date:___________________
2. Date of Birth:______________________SS.:______________________________ Sex:___________
3. Street Address:______________________________________________________________________
City/State/Zip Code:_________________________________________________________________
4. Home Tel.:_________________________________Work Tel.:_______________________________
5. Allergy to eggs: Yes/No
6. Previous Flu shot/Date:________________________________Allergy to Flu shot:________________
7. Any fever in the last 24 hours? Yes/No Last Menstrual Period:________________
8. Do you have a history of Guillain-Barre' Syndrome (a form of neurological disorder)? Yes/No
Despite a negative history of allergies to eggs and/or Flu shot, patients may still have a serious allergic or adverse reactions to the Flu vaccine, we therefore request that patients remain in the center for at least 30 minutes after the vaccine has been given.
I understand the information above and have had my questions on the vaccine answered. I have also provided the answers to the above questions truthfully. I request that I or my dependent be given the Flu vaccine.
______________________ _____________________
Patient/Parent or Guardian Date
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Patient's Temperature:______________________
Lot #:___________________________________ Expiration Date:______________________
Route/Site shot was given:__________________ Staff Signature:_______________________
Payment Amount/Method:_________________________________________________________________
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