Allergy Associates of Hartford, PC
Please fill out information. Please print clearly.
If you are not a patient of Allergy Associates of Hartford you must provide your complete information including insurance.
 Current Patient
 Family member of current patient:
Last Name:
First Name
Date of Birth
Age
Address:
City:
Insurance Information:
Patient/Parent Signature:
Date Vaccinated:
State:
Injection Site:
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R
Phone:
ID Number:
Nurses Signature:
Date:
All flu vaccines provided this year is a combination of A, B and the H1N1 vaccines. This is the only available flu vaccine this
year to providers.
Dosage: Only a single flu shot is needed for each season for persons 9 years of age and older. But children less than 9 years
may need a second shot after about a month. The doctor or nurse giving the flu shot will discuss this with parents or
guardians. Children should be given only a vaccine that has been chemically treated during manufacture (split virus) to
reduce chances of any side effects. Split virus vaccines can also be used by adults.
Possible side effects: Most people have no side effects from recent influenza vaccines. Flu shots are given by injections,
usually into a muscle of the upper arm. This may cause soreness for a day or two at the injection site and occasionally may
cause fever or achiness for one to two days.
Simultaneous Use of other Vaccines: The target group for influenza and pneumococcal vaccinations overlap. Both vaccines
can be given at the same time at different sites without increasing side effects. High risk children may also receive influenza
type B and oral poliovirus vaccines but at different sites. Influenza vaccine should not be given within 3 days of vaccination
with pertussis vaccine.
Questions: If you have any questions about the influenza vaccination, please ask now.
Reactions: you may get mild flu symptoms which will clear in a few days.
Pregnancy: If you are pregnant, please check with your OB-GYN before receiving the flu vaccine.
Age: We will be providing the flu vaccine to patients age 19 and up. 18 and under must receive the vaccine from their
primary care/pediatricians office.
I have read of have had explained to me the information on this form about influenza vaccine. I have had a chance to ask
questions which were answered to my satisfaction. I believe I understand the benefits and risks of influenza vaccine and
request that the vaccine be given to me or the person named above for which I am authorized to make this request.
Warning: Some people should check with a doctor before taking influenza vaccine
Yes
NO
Are you healthy today?
Are you ALLERGIC to EGGS?
Are you ALLERGIC to THIMERSAL?
Have you had Guillian Barre Syndrome?
Women: Are you pregnant?
Have you had the flu shot before?
Have you received the H1N1 before?
Copy of insurance card attached? Yes or No