Scribd
Upload
199 views1 page

Flu Vaccine Consent Form Template

Teresita G. Lansang, age 58, is being assessed for vaccination eligibility. She answers "no" to questions about prior allergic reactions, egg or chicken allergies, Guillain-Barre Syndrome, and pregnancy. She answers "yes" to having a chronic illness or medications. By signing the form, she consents to receiving the flu vaccine intramuscularly in the deltoid muscle. Reminders are provided about post-vaccination care.

Uploaded by

Rames Ely GJ
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
199 views1 page

Flu Vaccine Consent Form Template

Teresita G. Lansang, age 58, is being assessed for vaccination eligibility. She answers "no" to questions about prior allergic reactions, egg or chicken allergies, Guillain-Barre Syndrome, and pregnancy. She answers "yes" to having a chronic illness or medications. By signing the form, she consents to receiving the flu vaccine intramuscularly in the deltoid muscle. Reminders are provided about post-vaccination care.

Uploaded by

Rames Ely GJ
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Pre-Vaccination Assessment & Consent Form

Name: Teresita G. Lansang Birthday: October 3, 1961 Age: 58


School: PRADO SABA ELEMENTARY SCHOOL
No. Question Yes No
1 Have you had a severe (life threatening) allergic reaction to any component of the vaccine √
including egg protein or to a previous dose of any influenza vaccination?

2 Do you have a history of allergy to eggs or chicken? √


3 Do you have a history of Gullain-Barre Syndrome (a severe paralytic illness GBS)? √
4 Do you have any chronic illness or taking any maintenance medication? If yes pls. list down your √
medications.

5 Are you pregnant? √


6 Any medical related issue that the nurse should know? √

Attestation

By signing this form, I attest that the above given information is true and
correct to the best of my knowledge. Also I am giving my full consent to
administer the Flu Vaccine via Intramuscular on Deltoid Muscles.

Signature Over Printed Name / Date

Declination

I understand that I am eligible to receive Flu Vaccination, however, due


to personal reasons and/or religious beliefs, I am declining the
Vaccination.

Signature Over Printed Name / Date


Remarks:
1. Please be mindful of your schedule.
2. Please wear mask at all times.
3. Make sure that you have rested enough and avoid strenuous activities before injection.
4. In case of inflammation on injection site please use COLD COMPRESS.
5. In case of fever, drink Paracetamol 500 mg tabs as needed. If symptoms persist pls. consult your doctor.

Nurse on Duty / Date of Injection


Vaccine Given

You might also like