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)? 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 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: ________________________ 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: 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.