Influenza Vaccination Clinic Consent Form 2017-2018-2026

1. Click ‘Get Form’ to open the Influenza Vaccination Clinic Consent Form in the editor.
2. Begin by filling in your personal information. Clearly print your last name, first name, middle name, address, city, state, zip code, and phone number.
3. Enter your date of birth by selecting the month, day, and year. Indicate your gender by selecting either 'Male' or 'Female'.
4. Provide your age and your mother's first name. Answer the questions regarding pregnancy and any severe reactions to eggs or vaccines.
5. Confirm if you have had a fever within the past 24 hours. Review the provided Vaccine Information Statement and ensure you understand the benefits and risks of the influenza vaccine.
6. Sign and date the form at the bottom to authorize vaccination. Ensure all fields are completed before submission.

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