Influenza Vaccine Inactivated
Parent Vaccine Consent/Record
Information About Parent To Receive
Please Print
Child Name
______________________________________________ Date of Birth______________
(Please print clearly)
Parent Name
Date of Birth
(Please print clearly)
Home Address
City/ State/ Zip
☐ Male
☐ Female (check one)
Phone Number
Screening Questions
Have you ever had a reaction* to a previous dose of vaccine?
☐ Yes
☐ No
Do you have an egg allergy?
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
Do you have an allergy to any other food, medication or vaccine?
Have you had any vaccinations in the past 4 weeks?
Are you pregnant (if applicable)?
Comments:
I have read or have had explained to me the information in "Vaccine Information Statement (VIS):
Influenza Vaccine Inactivated: WHAT YOU NEED TO KNOW." I have had a chance to ask questions.
Any questions were addressed to my satisfaction. I believe I understand the benefits and risks of
Influenza vaccine and ask that the vaccine be given.
Signature of person to receive vaccine
Date: ______________________
X
VIS Date: 8/19/2014
VACCINE TO BE GIVEN: Influenza Vaccine (Inactivated)
For Clinic/Office Use ONLY (Please Print)
Signature & Title of Vaccine Administrator:
Clinic/Office Address: Highlands Integrative Pediatrics
2650 18TH Street, Suite 100, Denver CO 80211
Date Vaccine Administered:
Site and Route of Injection:
Vaccine Manufacturer:
Sanofi Pasteur
Vaccine Lot Number:
Reaction refers to a potentially serious condition such as a very high fever, difficulty breathing,
hoarseness or wheezing, hives, and/or swelling of the lips or tongue.