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H1N1 INFLUENZA VACCINE (SHOT) CONSENT/DECLINATION FORM. The H1N1 influenza vaccine is offered free of charge as a benefit to all employees, volunteers and students who qualify for vaccination based on CDC/APIC recommendations about who should get vaccinated this flu season.
2009 H1N1 Influenza Vaccine Consent Form for Use With Either Intramuscular, Injectable Formulation or Live Attenuated, Intranasal Formulation of Vaccine Author Centers for Disease Control and Prevention (CDC)
6 Νοε 2024 · A flu shot (influenza) vaccine consent form is a written authorization that gives a nurse or other medical practitioner the go-ahead to administer the flu vaccine. It should be signed by the patient, or, in the case of a minor, by a parent or legal guardian.
COMPLETE ONLY ONE OF THE FOLLOWING TWO OPTIONS: Option 1: Consent by the parent/guardian/legal substitute decision maker. Option 2: Consent by the client (including mature minor) hereby give consent for the individual named above to receive the following vaccine(s): Influenza.
23 Οκτ 2024 · Vaccine Information Statements are information sheets produced by CDC that explain both the benefits and risks of a vaccine to vaccine recipients. In the case of recipients under 18, they are provided to a parent or legal guardian.
INFLUENZA VACCINE CONSENT FORM. Patient’s Name: Date of Birth: MRN#. 1. Have you ever had an allergic reaction to flu vaccine? 2. Are you allergic to eggs, or egg product?
CONSENT FOR VACCINATION – I verify that I have read the current CDC Vaccination Information Statement and consent to receive the influenza vaccination.
