Influenza Vaccination Consent Form 2021

1

Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

MM/DD/YYYY

3

Email

example@example.com

Confirm Email

4

Please take a moment to read the Vaccine Information Statement before proceeding:

5

Informed Consent for Influenza Vaccination* This field is required.

By checking this box, I acknowledge that I have received, read, and understood the Vaccine Information Sheet for the indicated vaccine, and give my consent for its administration.

6

Are you allergic to eggs?* This field is required.

YESNO

7

If you answered YES to having an Egg Allergy, please call your SCC Coordinator at 714-965-2558, as we have a VERY LIMITED SUPPLY of the egg-free influenza vaccine. You may not be able to receive a vaccine on 9/18 and will be scheduled for a later date.

8

Are you over the age of 65?* This field is required.

YESNO

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Please select the type of influenza vaccination:

SENIOR HIGH-DOSE VACCINE: PF (*for those age 65 and over: Quadrivalent)

INACTIVATED INFLUENZA VACCINE: PF (*for those under age 65: Quadrivalent)

INACTIVATED INFLUENZA VACCINE: PF (*for those who are allergic to eggs: Egg-free)

10

Signature* This field is required.Your signature once again confirms that you have received, read, and understood the Vaccine Information Sheet for the indicated vaccine, and give your consent for its administration.

Clear

11

SignatureYour signature once again confirms that you have received, read, and understood the Vaccine Information Sheet for the indicated vaccine, and give your consent for its administration.

12

Signer's Name* This field is required.

First Name

Last Name