Pharmasave West November 2021
2021/2022 INFLUENZA VACCINE CONSENT FORM
1.
PATIENT INFORMATION
Patient Full Name
Address
Emergency Contact
Emergency Contact Phone Number
Physician/ Nurse Practitioner
Date of Birth
Age
Weight
Phone Number
Health Card Number
Physician/NP Phone Number
Gender
2.
COVID SCREENING AND HEALTH INFORMATION
As of today: Yes
No
Do you have a fever, infection, shortness of breath, chest pain or feel unwell
Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones? Symptoms include: fever, chills, cough,
shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle
aches, fatigue or loss of appetite, conjunctivitis, dizziness, confusion, nausea, vomiting, abdominal pain, skin
rashes, discolouration of fingers or toes - or any other suspected COVID-19 symptom?
Have you had a COVID-19 test in the past 14 days? If yes, please enter date and result.
Within the last 14 days, did you provide care or have close contact with a person with confirmed COVID-19
or someone who is under investigation for COVID-19?
Have you ever had a flu shot before?
Have you received any vaccinations in the last 6 weeks?
Have you ever fainted or had a serious reaction to any previous injection or vaccine(s) including Guillain-
Barre Syndrome?
Do you have any allergies? Please list: (foods, medications, vaccine components)
Do you have any chronic health conditions or immunodeficiencies? Please list:
Are you currently on any medications or immunosuppressants? Please list:
Do you have an active neurological condition?
Are you pregnant or breastfeeding?
Have you received blood products (containing immunoglobulin) in the last 3 months?
3.
PATIENT CONSENT
• I have read or had explained to me and understand the benefits, side effects and risks of receiving and risks of not receiving the
influenza vaccine.
• I have had the opportunity to ask questions and I have r
eceived satisfactory answers.
• I agree to stay in the pharmacy for at least 15 minutes after receiving the influenza vaccine or as directed by the pharmacists.
• I authorize my pharmacist to notify my physician/nurse practitioner and/or public health of the vaccine received, any adverse events
experienced and/or to contact me with any follow-up if needed.
AND:
I consent to receive the influenza vaccine today
OR
I consent on behalf of the patient to receive the influenza vaccine today
Print Name Relationship (if applicable)
Date
Phone Number
Signature __________________________________
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signature
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