Printable Flu Vaccine Consent Form Template

In Addition, I Am Aware That The Personal Health Information Collected On This Form May Be Shared With Another Healthcare Provider If It Is Required For My Care.

Influenza (flu) is a contagious disease that is caused by the influenza virus. The virus changes rapidly, which is why twice a year, new versions of the flu vaccine are developed. Flu shot consent form author: Vaccine consent form section 1:

The Flu Vaccine Is Publicly Funded For Everyone 6 Months Of Age And Older Who Lives, Works Or Attends School In Ontario.

Consent form for seasonal influenza (flu) vaccine i have read or have had explained to me the information about influenza and influenza vaccine. I, the undersigned, have read or had explained to me the vaccine information sheet (vis). I request that the vaccine be given to me. I consent to the seasonal influenza vaccine.

I Understand The Benefits And Risks Of The Influenza Vaccination As Described.

Flu vaccine form patient name: Influenza (flu) is a very contagious respiratory virus that causes outbreaks of varying severity almost every winter. Please be aware you are responsible for knowing your insurance benefits and payment coverage. Ask questions and have had them answered to my satisfaction.

The Influenza Vaccine, Or Flu Shot, Protects You Against The Infections That Can Be Caused By The Influenza Virus.

Information about patient to receive vaccine (please print) patient’s name:__________________________________________ birth date:____/____ /________ The influenza virus can mutate from year to year and protection from a dose of flu vaccine wanes over time, so last year’s vaccine will not protect you this year. If signing for someone other than yourself, indicate your relationship to that other person: By signing this form, i atest that i have reviewed the influenza vaccine information statement (vis) and have had an opportunity to ask questions.