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Influenza consent form

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The document is an Influenza/Pneumococcal Immunization Consent Form from the New York State Department of Health, designed to collect personal information and medical history for individuals receiving vaccinations. It includes sections for consent, health screening questions, and signatures from both the recipient and healthcare provider, ensuring that patients understand the benefits and risks associated with the vaccines.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in your personal information, including your name, date of birth, sex, and address. Ensure all details are accurate for proper processing.
For individuals under 19 years old, provide the mother’s maiden name and Medicare claim number if applicable.
Complete the health-related questions regarding allergies, current illnesses, and vaccination history. Answer each question honestly to ensure safety.
Review the consent sections for both influenza and pneumococcal vaccinations. Make sure you understand the information provided before signing.
Sign and date the form at the designated areas for yourself or as a guardian. This confirms your consent for vaccination.
Finally, submit the completed form through our platform for processing by your healthcare provider.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (209 Votes)
2010	4.4 Satisfied (484 Votes)

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Is it secure to sign my influenza consent electronically?

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How do you get influenza immunization consent for my state?

If you are searching for a state-specific influenza immunization consent sample, you can find it in our DocHub Forms & Templates catalog. Use the search field, key in your form’s name, and search through the results for your state. You may also filter out irrelevant results while searching our catalog by categories.

What is in the flu shot?

Ingredients often include deactivated influenza viruses, chemicals that boost the bodys response to the vaccine, preservatives to prevent contamination, and stabilizers. The CDC recommend getting a flu shot in September or October, but getting one any time during flu season will help.

Which flu is the flu shot for?

Most flu vaccines in the United States protect against four different flu viruses (quadrivalent); an influenza A (H1N1) virus, an influenza A (H3N2) virus, and two influenza B viruses.

How flu is created?

In humans, influenza viruses are primarily transmitted through respiratory droplets produced from coughing and sneezing. Transmission through aerosols and intermediate objects and surfaces contaminated by the virus also occur. InfluenzaInfluenza virus, magnified approximately 100,000 timesSpecialtyInfectious disease10 more rows

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Is a live vaccine?

High-Dose Quadrivalent vaccine contains 4 killed flu virus strains. There is no live flu virus in High-Dose Quadrivalent. High-Dose Quadrivalent cannot cause the flu. Inactive ingredients include formaldehyde and octylphenol ethoxylate.

Form flu 2025

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Is it secure to sign my influenza consent electronically?

How do you get influenza immunization consent for my state?

What is in the flu shot?

Which flu is the flu shot for?

How flu is created?

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Is a live vaccine?

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