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4011 West Plano Parkway
Suite 106
Plano, 75093
469-241-1954
INFLUENZA IMMUNIZATION CONSENT
Flu
Influenza (flu) is a respiratory disease caused by influenza virus infection. The types or strains, of influenza virus that cause
illness may change from year to year, or even within the same year. People who get flu may have fever, chills, headache, dry
cough, and muscle aches, and may be sick for several days to a week or more. Most people recover completely. However, for
some people, flu may be especially severe, and pneumonia or other complications, including death, may occur.
Vaccine
The regular flu vaccine contains killed influenza virus of the types selected by the U.S. Public Health Service and the Center for
Biologics Evaluation & Research of the U.S. Food and Drug Administration. The types of virus included are those that have
most recently been causing influenza. The vaccine will not give you flu because it is a killed virus vaccine. As with any
vaccine, flu vaccine may not protect 100% of all susceptible individuals.
Patient Information Section
____________________________________
Patient Last Name
________________________
First Name
________________________________
Patient Address: Street
______________________
City
______________________________________________
Signature (Person receiving vaccine or Parent or Guardian)
___/____/____
_______
Middle I
Birth Date M/D/Y
_________
State
__________
Zip
Self, Spouse, Child, Other
(Circle 1) Relationship
___
Age
___
Sex
______-______-_____
Daytime Phone Number
___________________/______________
Emergency Contact Person/ Phone Number
By signing, I am confirming I am not allergic to eggs or egg products or Thimerosal, do not have acute febrile illnesses (Fever>101º F) and
have not had an anaphylactic reaction or developed Guillain-Barré syndrome after receiving a previous influenza vaccination.
If you have any questions, please ask now or check with your physician before receiving the vaccine. I understand the benefits and risks of
these vaccinations and request those indicated above to be given to me. If you experience any significant reactions, see your physician.
There is a $25.00 service charge for returned checks.
For Clinic Use Only below this point:
Vaccine Administered (nurse checks box by vaccine given)
Influenza
Lot #
Fluzone (SP) >6 mos High Dose (SP) >65 yrs
Flulaval (GSK) >18yTri  Quad Fluarix (GSK) >3 yrs
Nurse Signature:
RN Date :
Payment Amount:
CASH
Exp Date
Amount/Site
June
0.5 ml >3y IM
0.25ml < 3y IM
CHECK#
OTHER:
Injection
Site
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BILL