INFLUENZA VACCINE CONSENT FORM 2021 2022 - Ottawa Public Health-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your last name and first name in the designated fields. This ensures that your consent is properly attributed.
3. Fill in your date of birth, age, and complete address including street, city, province, and postal code. Accurate information is crucial for record-keeping.
4. Indicate whether you have a chronic medical condition by circling 'Yes' or 'No'. If applicable, specify the condition.
5. Answer the allergy question similarly. Circle 'Yes' or 'No', and provide details if you have any allergies.
6. Read the information about the influenza vaccine provided on the back of the form. Confirm your understanding by signing and dating the form.
7. If consenting on behalf of someone else, circle 'Yes' and fill in the legal guardian's full name and phone number along with their relationship to the individual receiving the vaccine.

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