Flu Vaccine Consent Form

CREDIT VALLEY HEALTH CENTER 905-828-0270

Screening Questionnaire and Consent Form for Influenza Vaccine 2020-2021

* Indicates required field

Patient Name *

First

Last

Health Card Number *

Date of Birth (MM/DD/YYYY) *

phone number (Xxx-xxx-xxxx) *

Parent/Guardian Name (If under 16) *

First

Last

Email *

Section 2: COVID-19 Screening

Have you travelled outside of Canada in the past 14 days? *

Yes No

Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate personal protective equipment? *

Yes No

Are you experiencing any of the following symptoms? *

Yes No

- Fever
- New onset of cough
- Worsening chronic cough
- Shortness of breath
- Difficulty breathing
- Sore throat
- Difficulty swallowing
- New or unusual worsening of chronic conditions
- Low blood pressure for your age
- Fast heart rate

- Decrease or loss of sense of taste or smell
- Chills
- Headaches
- Unexplained fatigue/lethargy/malaise/muscle aches (myalgias)
- Nausea/vomiting, diarrhea, abdominal pain
- Pink eye (conjunctivitis)
- Runny nose or nasal congestion without other known cause
- For infants and young children: decreased or lack of appetite/difficulty feeding

If you are older than 70 years of age, are you experiencing any of the following symptoms? *

Yes No

- Delirium
- Unexplained or increased number of falls
- Acute functional decline

If you respond YES to ANY of the screening questions in Section 2, you should not receive a flu shot at the clinic at this time and should speak with your doctor. If the responses to ALL of the screening questions in Section 2 are NO, proceed to Section 3.

Section 3: Screening Questionnaire

For adult patients as well as parents of children (<16 years of age) to be vaccinated:
The following questions will help us determine if there is any reason you or your child should not get the flu shot today. If you answer “yes” to any question, it does not necessarily mean the shot cannot be given. It simply means additional questions must be asked.
If a question is not clear, please ask your doctor/nurse to explain it.

Are you allergic to any part of the flu shot, or have you had a severe, life-threatening allergic reaction to a past flu shot? *

Yes No Unsure

Have you had wheezing, chest tightness or difficulty breathing within 24 hours of getting a flu shot? *

Yes No Unsure

If YES or UNSURE for either of these answers, do NOT get the shot & SPEAK WITH YOUR DOCTOR

Have you had a reaction to eggs or egg products? *

Yes No Unsure

If YES or UNSURE, speak to the doctor/nurse, you may be able to receive the flu shot but may require a longer observation period post-administration.

Have you had Guillain-Barré Syndrome within 6 weeks of getting a flu shot? *

Yes No Unsure

If YES, do not get the flu shot and SPEAK WITH YOUR DOCTOR

Do you have a new or changing neurological disorder? *

Yes No Unsure

If YES, do not get the flu shot & SPEAK WITH YOUR DOCTOR

Do you have bleeding problems or use blood thinners? (e.g. warfarin, low dose or regular strength aspirin) *

Yes No Unsure

If YES, shot can be given but apply gentle pressure afterwards

Section 4: Consent Given By Patient/Agent

I, the undersigned client, parent or guardian, have read or had explained to me information about the flu shot and I have had the chance to ask questions, and answers were given to my satisfaction. I understand the risks and benefits of receiving the flu shot. I agree to wait in the clinic for 15 minutes (or time recommended by the doctor/nurse) after getting the flu shot. I am aware that it is possible (yet rare) to have an extreme allergic reaction to any component of the vaccine. Some serious reactions called “anaphylaxis” can be life-threatening and is a medical emergency. If I experience such a reaction following vaccination, I am aware that it may require the administration of epinephrine, diphenhydramine, beta-agonists, and/or antihistamines to try to treat this reaction and that 9-1-1 will be called to provide additional assistance to the immunizer. The symptoms of an anaphylactic reaction may include hives, difficulty breathing, swelling of the tongue, throat, and/or lips. In the event of anaphylaxis, I will receive a copy of my medical record that contains information on emergency treatments that I had received, or a copy will be provided to my agent or EMS paramedics.

Choose Any *

I confirm that I want to receive the seasonal influenza vaccine I confirm that I want my child to receive the seasonal influenza vaccine

Patient Name *

First

Last

PARENT/GUARDIAN Name (if applicable) *

First

Last

PATIENT/PARENT SIGNATURE *

The submission of this consent form and the electronic delivery of the signature on this form will be treated in all respects as having the same force and effect as an original signature

Submit

​Screening Questionnaire and Consent Form for Influenza Vaccine 2020-2021

​Section 2: COVID-19 Screening

Section 3: Screening Questionnaire

Section 4: Consent Given By Patient/Agent

Screening Questionnaire and Consent Form for Influenza Vaccine 2020-2021

Section 2: COVID-19 Screening