Fillable Ifyouanswer"Yes"toanyofthefollowing3questions,pleaseDONOTattendthefluclinictoday. InfluenzaImmunizationRecord Forthesafetyofthevolunteersandstaff,andforyourhealth,pleaserescheduleyourappointment. 1. D

Fill Online, Printable, Fillable, Blank Ifyouanswer"Yes"toanyofthefollowing3questions,pleaseDONOTattendthefluclinictoday. InfluenzaImmunizationRecord Forthesafetyofthevolunteersandstaff,andforyourhealth,pleaserescheduleyourappointment. 1. D Form

Use Fill to complete blank online OTHERS (CANADA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Ifyouanswer"Yes"toanyofthefollowing3questions,pleaseDONOTattendthefluclinictoday. InfluenzaImmunizationRecord Forthesafetyofthevolunteersandstaff,andforyourhealth,pleaserescheduleyourappointment. 1. DoyouhaveCOVID19orflulikesymptoms(e.g.fever,suddencough,difficultybreathing)? 2. Inthelast14days,haveyouoranyclosecontactstravelledoutsideofCanada? 3.

On average this form takes 6 minutes to complete

The Ifyouanswer"Yes"toanyofthefollowing3questions,pleaseDONOTattendthefluclinictoday. InfluenzaImmunizationRecord Forthesafetyofthevolunteersandstaff,andforyourhealth,pleaserescheduleyourappointment. 1. D form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 25 other fields

Country of origin: CANADA
File type: PDF

BROWSE OTHERS (CANADA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
InfluenzaImmunizationRecord
LastName
FirstName
Age(Years)
Sex
F M
DateofBirth(DD‐MMM‐YYYY)
‐‐
PersonalHealthNumber (XXXX‐XXX‐XXX)
‐‐
Phone(XXX‐XXX‐XXXX)
Ifyouanswer"Yes"toanyofthefollowing3questions,pleaseDONOTattendthefluclinictoday.
Forthesafetyofthevolunteersandstaff,andforyourhealth,pleaserescheduleyourappointment.
1. DoyouhaveCOVID‐19orflu‐likesymptoms(e.g.fever,suddencough,difficultybreathing)?
2. Inthelast14days,haveyouoranyclosecontactstravelledoutsideofCanada?
3. Inthelast14days,haveyouoranyoneinyourhouseholdbeeninclosecontactwithaconfirmed
COVID‐19caseorarepartofcontacttracingforCOVID‐19?
Pleaseanswerthefollowingquestionsandmark“X”intheappropriatebox Yes No
1. Haveyoueverfaintedduringorafteraninjection?
2. Doyousevereallergiestofood,medications,componentsofavaccine(e.g.eggsoregg
products,gelatin,neomycin,gentamicin,formaldehyde,kanamycin,neomycin),orlatex?

3. HaveahistoryofGuillain‐BarreSyndrome(muscleweakness,difficultywalkingsteady,paralysis)
within6weeksofaflushot?

4. Childrenage<9Haveyoupreviouslyreceived2dosesofinfluenzavaccine4weeksapart?

5. Childrenage2‐17whowishtoreceiveFlumist(nasalspray)
Doyouhaveanimmunesystemweakenedbydiseaseormedicaltreatment?
Doyouhavesevereasthmaoractivewheezing?
Doyoutakeaspirin‐orsalicylate‐containingmedicationsforlongperiodsoftime?
HaveyoureceivedMMR(measles‐mumps‐rubella)orvaricellazoster(chickenpox)vaccinein
thepast4weeks?
Doyouhaveclosecontactwithpeoplewhohaveaseverelyweakenedimmunesystem?

6. FemaleonlyAreyoucurrentlypregnantorbreastfeeding,orplanningtowithinthenextmonth?

Iunderstandthevaccinemayhavethefollowingpotentialrisksandsideeffects:
Soreness,redness,swellingattheinjectionsiteforafewdays
Flu‐likesymptomswhichtypicallyresolvewithinafewdays(mildfever,chills,malaise,muscleaches)
Rarehypersensitivityreaction(itchiness,hivesorswelling)
Iacknowledgetheaboveandhavehadanopportunitytoaskquestionswhichwereansweredtomy
satisfaction.Iunderstandandagreetoremainatthelocationfor15minutesaftertheinjection.
ParticipantorParent/GuardianSignature:
Date:
CLINICUSE:IMsite(circle)
Deltoid: Left Right
Thigh: Left Right

ImmunizerName:
Date:
VaccineLabel
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

IfyouanswerYestoanyofthefollowing3questions,pleaseDONOTattendthefluclinictoday. InfluenzaImmunizationRecord Forthesafetyofthevolunteersandstaff,andforyourhealth,pleaserescheduleyourappointment. 1. DoyouhaveCOVID19orflulikesymptoms(e.g.fever,suddencough,di

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document