FLU VACCINATION REGISTRATION AND CONSENT FORM

(Westbound Market, Bulua, Cagayan De Oro City)

CLIENT INFORMATION

Full Name: _________________________________________ Date of Birth: _______________

Sex: ________________ Age: _____________ Contact Number: _________________________
Home Address: _________________________________________________________________

PRE VACCINATION SCREEENING

Yes No Details
1. Are you well today?
2. Do you have flu-like symptoms (e.g runny-nose, fever)
3. Do you have any medical conditions that we should be
aware of? (e.g Diabetes Mellitus, Hypertension)
4. Have you received any other vaccination in the last
months?
5. Do you suffer from asthma?
6. Do you have problems with previous flu shots?
7. Are you pregnant?
8. Do you have any Allergies?

I have read and explained to me the vaccine information about Flu vaccine. I have a
chance to ask question that were answered to my satisfaction. I believe I understand the
benefit and risks of the Flu vaccine and ask that the vaccine given to me or the person named
above for whom I am authorized to make this request.
DISCLAIMER
The client agrees to assume the risk of flu Vaccination and further agree to hold harmless to
the Healthcare provider and its staff members for conducting Flu Vaccination from any and all
claims, suits, losses or related causes of action for damages may not be held liable, including
but not limited to, such claims that may result from my injury or death, accidental or
otherwise, during or arising in any way from the Flu Vaccination program.

SIGNATURE ABOVE PRINTED NAME: _____________________________________________

DATE: ________________________________

FOR HEALTHCARE PROVIDER ONLY

VACCINE DOSE Lot Number Expiry Date Site/ Time Given Date
IM Given

Given by:

GIFT V. PAGUNTALAN, MAN, RN

License No: 0582653

VITAL SIGNS MONITORING

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