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Flu Vaccine Consent Form (download PDF) - York Hospital

Flu Vaccine Consent Form (download PDF) - York Hospital 2025

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The document is an Influenza Vaccine Consent and Administration Record for the 2013-14 season, detailing patient screening questions regarding allergies and previous reactions to the vaccine. It includes a consent section for patients to acknowledge understanding of the vaccine's benefits and risks, along with personal and billing information for the individual receiving the vaccine.

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Click ‘Get Form’ to open the Flu Vaccine Consent Form in the editor.
Begin by answering the allergy questions. Indicate 'Yes' or 'No' for each of the five questions regarding allergies and previous reactions.
In the PATIENT CONSENT section, read through the information provided about the influenza vaccine. Ensure you understand it before proceeding.
Fill in your personal details in the PATIENT BILLING INFORMATION section. Include your name, date of birth, address, phone number, and physician's name.
Provide your Medicare ID or insurance information as required, including policy and group numbers.
Sign and date the form at the bottom to confirm your consent for vaccination.
For office use only, ensure that injection site details are filled out correctly by healthcare personnel after vaccination.

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What questions do they ask before a flu shot?

Is the person to be vaccinated sick today? Does the person to be vaccinated have an allergy to an ingredient of the vaccine? Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? Has the person to be vaccinated ever had Guillain Barr syndrome?

What do you put on flu declination form?

I understand that if I choose to decline the influenza vaccine, and my job duties may cause me to infect patients or to become infected, I will be required to wear a surgical mask or respirator, as appropriate, within 6 feet of patients or in designated areas during influenza season.

Why does the flu consent form ask if you are currently ill?

People who are moderately or severely ill should usually wait until they recover before getting influenza vaccine. Your health care provider can give you more information. Guillain-Barr Syndrome (GBS) after inactivated influenza vaccine (the flu shot).

Can you get a flu shot if you have a sore throat?

Its safe to receive the flu shot if youre sick with a mild illness. Some examples of a mild illness include colds, sinus infections, and mild diarrhea. A good rule of thumb is to speak to your doctor prior to receiving the flu shot if youre currently sick with a fever or have a moderate to severe illness.

What are the CDC guidelines for the flu?

Note: Not everyone with flu will have a fever. Individuals with suspected or confirmed flu, who do not have a fever, should stay home from work at least 4-5 days after the onset of symptoms. Persons with the flu are most contagious during the first 3 days of their illness.

What are valid reasons to decline the flu shot?

Other reasons included thinking they do not need a flu vaccine, fear of getting sick, fear of side effects from vaccination, being allergic to the vaccine, and thinking that flu vaccination is not good for you. Source: CDC, 2016.

Flu Vaccine Consent Form (download PDF) - York Hospital 2025

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