CONSENT FORM FOR

FLU VACCINE
Name : _______________________________________________ Age: _______________ Gender: _____
DOB: ________________ Mobile/Contact No.: ______________________________________________
Parent/Guardian's Name: _______________________________________________________________
Address: _________________________________________________________________________________

THIS FORM CONFIRMS THAT YOU HAVE GIVEN YOUR CONSENT TO RECEIVE INFLUENZA VACCINATION.

Do you have any of the following at the moment? Put an X mark if the answer is NO.
____ Currently feeling unwell ____ Fever
____ History of bleeding disorder ____ Previous severe response to flu vacc
____ Allergy to eggs ____ Received treatment to cancer in the
last 12 months

Signature of Patient/Parent/Guardian: ______________________________ Date: _______________

INFLUENZA VACCINATION RECORD

Name of Patient: __________________________ Age: ______
Date: _________________ 
Brand / Lot No.: ___________________
Injection Site: __________________________

Provider: ________________________________
Contact No.: _____________________________