Hawarden Regional Healthcare Clinic 
Seasonal Pediatric Influenza Vaccine Consent Form 2022-2023

Print Name:  ________________________________________ Date of Birth:  _____________________
Address:  __________________________________ Town/State/Zip Code:  _______________________
Phone number:  _____________________________________________________________________
Insurance name: _______________ ID number: ______________ Group: _______________

  Yes       No		
 	1. Are you currently ill AND have fever greater than 101 degrees?	
	2. Are you allergic to eggs?	
	3. Have you ever had a severe reaction to the flu vaccine?	
	4. Have you had Guillian-Barre Syndrome?	

You should not receive the Influenza vaccine if you have ever had a serious allergic reaction to a previous dose of influenza vaccine; you have a history of Guillain-Barre Syndrome (GBS); you are ill. An egg-free alternative may be available; please ask about this.

If you have had recent chemotherapy, radiation therapy, or steroids these conditions may decrease the 
effectiveness of the vaccine. However, flu vaccination is still recommended. Flu vaccination is recommended for any woman who will be breastfeeding during the influenza season, or will be pregnant during the influenza season. Vaccination can occur in any trimester.

I understand that the usual post-inoculation reactions are all that may normally be anticipated and I will take the responsibility to seek medical attention should more severe symptoms occur.

Consent

I have read the Influenza vaccine information sheet dated 8/6/2021. I have been provided an opportunity to ask questions about the disease and the treatment. I understand the risks and benefits of the vaccination. I understand that the vaccination that I am about to receive is a single shot and it will not be fully effective for approximately two weeks.
However, as with all vaccines there is no guarantee that I will become immune or that I will not experience side effects. I understand that I should not receive this vaccine if I have had a severe reaction to a previous influenza vaccine, or if I have had Guillain-Barre Syndrome.
I hereby release Hawarden Regional Healthcare from all responsibility for reactions that may occur from this immunization against influenza. I hereby consent to have the influenza vaccine.

Signature of Vaccine Recipient or Parent/Guardian:  _________________________________ 

If Parent/Guardian, please print name: ____________________________________________

Date: ________________	

•	Do you have Commercial Insurance that covers the Influenza Vaccine?   Yes    No
•	Are you underinsured (have health insurance that DOES NOT pay for vaccinations)?   Yes    No
•	Are you enrolled in Medicaid?   Yes    No
•	Are you an American Indian or Alaskan Native (AI/AN)?   Yes    No

Name of flu vaccine: ___________   Dose: ________    NDC: ____________________________
Lot #: _____________ 	Expiration Date: _________

For office use only:				
Date of Administration: _______________________
Administered by: _________________________
Location (circle): 	Right Deltoid	Left Deltoid       
		   	Right Thigh	Left Thigh