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Consent Form Influenza Quadrivalent Vaccine Consent Form Section 1: Information for Individuals receiving the 201617 Quadrivalent Influenza Vaccine (please print) NAME (Last) (First) (M.I.) DATE OF
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How to fill out influenza quadrivalent vaccine consent

01
Read the influenza quadrivalent vaccine consent form carefully.
02
Collect all necessary personal information, such as name, date of birth, and contact information.
03
Provide information about any allergies or medical conditions that may affect your eligibility for the vaccine.
04
Ensure that you understand the risks and benefits associated with the influenza quadrivalent vaccine.
05
Sign and date the consent form to indicate your agreement and understanding of the information provided.
06
Return the completed consent form to the appropriate healthcare provider or vaccination center.

Who needs influenza quadrivalent vaccine consent?

01
Individuals who are eligible to receive the influenza quadrivalent vaccine.
02
People who are at increased risk of complications from influenza, such as young children, older adults, pregnant women, and individuals with certain medical conditions.
03
Healthcare workers, as they may be exposed to patients with the influenza virus.
04
Individuals who live or work in close proximity to others, such as in nursing homes, dormitories, or similar settings.
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Anyone who wants to protect themselves and others from the flu virus.
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Influenza quadrivalent vaccine consent is a form that gives permission for the administration of the quadrivalent influenza vaccine.
Any individual receiving the quadrivalent influenza vaccine is required to file the consent form.
Influenza quadrivalent vaccine consent can be filled out by providing personal information, signing and dating the form.
The purpose of influenza quadrivalent vaccine consent is to ensure that individuals understand the risks and benefits of receiving the vaccine.
Information such as name, date of birth, medical history, allergies, and signature must be reported on the consent form.
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