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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 … 


I hereby certify that the foregoing history is true and complete to the best of my knowledge and I have received and read the“Vaccine Information Statement” from the CDC, have had an opportunity to ask questions that were answered to my satisfactions and do wish to receive the flu vaccine fully understanding the risks and the benefits. 

Flu Vaccine Consent Forms - Pharmasave - Pharmasave

If you do not have a printer, the pharmacy can provide you with a blank form to fill out at the pharmacy. Due to privacy reasons, please do not email your completed form. Contact your local Pharmasave store for specific details about getting your … 

Employee Flu Vaccination Declination Form

I may change my mind and accept vaccination later, if vaccine is available. I have read and fully understand the information on this declination form. Print name Department . Signature Date . I decline vaccination for the following reason(s). Please check all that apply. I believe I will get the flu if I get the shot. I do not like needles. 


Serious reaction to previous flu vaccine. 3. History of Guillain-Barre syndrome. 4. Moderate or severe illness. I understand that as with any medication, serious problems, even death can occur. The risks from the vaccine are much smaller than the risks from the disease. Almost all people who get influenza vaccine 

Message to Employees: Distribute by e-mail, letter, flyer etc

Get the vaccine for seasonal flu [insert information about vaccination clinics at the workplace or other ways your business can support getting vaccinated for seasonal flu] Get the 2009 H1N1 flu vaccine when it becomes available, if. you are at higher risk for 2009 H1N1 flu complications. People at higher risk for 2009 H1N1 flu complications 

Knock Out Flu at Work - Home :: Washington State

6 Get a Flu Shot Here! Host a flu vaccine clinic in the workplace and use this flyer. Add the location, date, and time of your flu vaccine clinic and let employees know so they can plan to conveniently attend. 7 Links and Partner Resources. There are many online resoures for both employers and employees with trusted flu vaccine information. These 

Forms & Templates |

Nov 12, 2021 · On this page, you will find various forms that Military Health System uses to support its programs. Please scroll down the page or use the search box to find specific forms and templates. Please note that files more than two years old may not be compliant with Section 508 of the Rehabilitation Act. 

Documenting Vaccinations | CDC

Health care providers are required by law to record certain information in a patient’s medical record. This record can be in electronic or paper form. Health care providers who administer vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the permanent medical record of the recipient indicates: 

Vaccine Administration Record (VAR)—Informed Consent for

Vaccine Administration Record (VAR)—Informed Consent for Vaccination Email address: Race: American Indian or Alaska Native Asian . Native Hawaiian or Other Pacific Islander I may prevent, by using a state-approved opt-out form or, as permitted by my state law, an opt-out form (“Opt-Out Form”) furnished