Pharmacy Copy
Influenza Immunization Record Save-On-Foods #:
Last Name First Name Date of Birth (MM-DD-YYYY) Age (yrs.) Sex
Male Female
Personal Health Number Address Phone (Home)
Postal Code Phone (Other)
Emergency Contact Last Name First Name Emergency Contact Phone No
Please answer the following questions and check an “X” in the appropriate box
Yes No N/A
Is this your first flu shot?
Do you have a respiratory infection, fever, sudden cough, difficulty breathing, other flu-like
or COVID-19 symptoms, and/or
risk of COVID-19 exposure? If yes, do not attend flu clinic refer to for COVID-19 self-assessment)
Have a history of Guillain-Barre Syndrome within 6 weeks of getting a flu shot?
Have you ever fainted during or after an injection?
Have you received any vaccinations in the last 4-6 weeks? Which ones?
Do you have severe allergic reactions to any medic
ations, components of a vaccine (e.g. neomycin, gentamicin, neomycin,
formaldehyde, kanamycin, egg or egg products) or latex?
Are you <5 years of age? (children < 5 years of age will be immunized by public health) Note: Children <9 yrs. of age and
have never received a dose of influenz
a vaccine require, 2 doses with a minimum spacing of 4 weeks between doses.
First Dose Second Dose
Are you on any steroids or immunosuppressive, anticancer, antiviral, or any medications that affect the immune system?
Do you have cancer, leukemia, HIV, or any other immune system problems?
During the past year, have you received a blood transfusion, or been given medication called immune (gamma) globulin or
had radiation therapy?
Female only: Are you pregnant or breastfeeding, or planning to get pregnant or breastfeed within the next month?
I understand there may be some soreness, redness, and s
welling at the injection site for a few days. Less common reactions include mild fever,
malaise, and/or muscle aches (flu-like symptoms) and may typically resolve within 2-3 days. As with any vaccine, hypersensitivity
reaction is possible. This is rare, but may include itchiness, hives, and/or swelling. Save-On-Foods Limited Partnership (“SOF”) has provided
me with information of other risks related to the vaccine. I request and authorize SOF, through its employees and contractors, to administer the
vaccine by injection. I have read and understand the risks of the vaccination and I acknowledge that I have had an opportunity to ask questions
which were answered to my satisfaction. In return for the vaccination, I agree to release SOF (including its employees, directors, officers, and
contractors) from any and all liability, claims, injury, damages, costs, expenses and compensation whatsoever, howsoever arising, from or in
any way connected with the vaccination.
I understand and agree to remain at the location for 15 minutes after the injection as directed by the pharmacist. In the event of an emergency, I
authorize the pharmacist to administer epinephrine and/or apply necessary life-saving procedures as an interim measure until medical support
personnel arrive. I have read and understand the above information.
_________________________________ _______________________________________________ _________________________
Participant Name (Please Print) Participant/Parent/Caregiver Signature Date
dose 2
Priority List by Reason Code:
*(specific to children < 9 years after receiving first flu vaccination)
46 Pregnant women 05666646 FluLaval® Tetra (GSK) 0.5mL Lot # / Exp.
02 Greater than or equal to 65 years of age 05666602 Fluzone® (SF) 0.5mL Lot # / Exp.
67 Children 6 months to 59 months of age N/A Afluri Tetra (Seqirus) 0.5mL Lot # / Exp.
5 yrs. to 64 yrs. of age with an eligible chronic condition
and/or belong to a high-risk population
05666606 Influvac® Tetra (Mylan) 0.5mL Lot # / Exp.
Household or close contacts of individuals in the 46, 02,
67, and 68 reason codes & of children < 6 mos. of age
Fluzone® High Dose
(SF) 0.5mL
Lot # / Exp.
5 yrs. to 64 yrs. (routine) with no individual risk or not a
household contact of an individual in a high-risk pop.
05666605 Other: Lot # / Exp.
Injection Date: Injection Time:
Arm Left
Immunizer’s Name (Print)
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