Dr - Highlands Integrative Pediatrics

Influenza Vaccine Inactivated
Child Vaccine Consent/Record
Information About Child To Receive
Please Print
Child Name
Date of Birth
(Please print clearly)
Home Address
City/ State/ Zip
☐ Male
☐ Female (check one)
Phone Number
Screening Questions
Has your child ever had a reaction* to a previous dose of vaccine?
☐ Yes
☐ No
Does your child have an egg allergy?
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
Does your child have an allergy to any other food, medication or vaccine?
Has your child had any vaccinations in the past 4 weeks?
Is your child pregnant (if applicable)?
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 on behalf of my child.
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 to my child.
Signature of parent or legal guardian
Date: ________________________
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:
0.25 mL OR 0.5 mL
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.
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