2014-2015 Inactivated Influenza Vaccine Consent Form

2014-2015 Inactivated Influenza Vaccine Consent Form
Name of Individual to be Immunized _____________________________________________________
Address ___________________________________________________ Phone # __________________
Date of Birth_______________________________ Age______________ M F
ID# ___________________________________
Please answer the following questions:
Are you sick or do you have a high fever today? Yes No Unknown
Are you allergic to chicken, eggs, or egg products? Yes No Unknown
Have you ever had an allergic reaction to a flu shot? Yes No Unknown
Are you pregnant, or think you may be? Yes No Unknown
Do you have a blood clotting disorder or are you taking
blood thinning medication? Yes No Unknown
Acknowledgement:
1. I am at least 18 years of age. I have read or have had explained to me the inactivated influenza
vaccine: “What you need to know”, vaccine information sheet. I have been given the opportunity to
ask a USC health care professional concerning the influenza vaccine, including the risks and benefits
of receiving the influenza vaccine. All of my questions concerning the vaccine have been answered
to my satisfaction. I understand the benefits and risks of the influenza vaccine and request that it be
given to me.
2. I affirm that I am not allergic to e ggs, chicken, thimerosal, albumin products or a previous dose of t he
influenza vaccine. I do not have a history of Guillain-Barre’ Syndrome (GBS).
3. I understand my medical care provider may submit this immunization information to the state
immunization registry.
Release of Liability:
I have read and I understand the acknowledgements set forth above, and I hereby release the University
of Southern California and USC Care Medical Group and their affiliated entities, and all of their agents,
employees, trustees, and representatives, from any and all liability which may arise from the vaccination
and/or from the information provided to me concerning such vaccination.
Consent to the Vaccination:
I have read and I understand the information set forth in thi s form. Based on that understanding, I hereby
CONSENT to an inactivated influenza vaccination provided to me by USC Care Medical Group.
______________________________________________ _________________________
Signature of Recipient of the Vaccination Date
If signed by someone other than recipient, please indicate name and relationship. _______________________________
___________________________________________________ _________________ ______________________________________
Signature of Witness Date P rinted Name of Wit ness
For Office Use Only
Flu vaccine Lot #: _____________ Exp: __________ Dat e: ____________ _______
Site o f I nje c tion: R L Deltoid ________________
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2014-2015 Inactivated Influenza Vaccine Consent Form PDF

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