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Trumbull Health Department 335 White Plains Road, Trumbull, CT 06611 Phone (203) 4521030 Fax (203) 4521050INFLUENZA VACCINE CONSENT FORM Standard Quadrivalent VaccineHigh Dose Influenza Vaccine Patients

How to fill out influenza vaccine consent form

How to fill out influenza vaccine consent form

1. Start by reading the influenza vaccine consent form thoroughly to understand all the information and requirements.
2. Provide your personal details accurately, such as your full name, date of birth, address, and contact information.
3. Answer the medical history section honestly, including any allergies, previous adverse reactions to vaccines, or current medical conditions.
4. Indicate whether you are currently taking any medications or if you have had any recent surgeries.
5. Specify if you have received any other vaccines recently or if you are planning to receive any other vaccines in the near future.
6. If applicable, state if you are pregnant, breastfeeding, or planning to become pregnant.
7. Sign and date the consent form to acknowledge that you understand the risks and benefits of the influenza vaccine and agree to receive it.
8. If required, provide the name and contact information of your primary healthcare provider or the clinic administering the vaccine.
9. Double-check all the information you have provided before submitting the consent form.
10. Keep a copy of the completed consent form for your records.

Who needs influenza vaccine consent form?

1. Anyone who wishes to receive the influenza vaccine needs to fill out the influenza vaccine consent form.
2. This includes individuals of all ages, from children to adults, who want to protect themselves against the flu virus.
3. Additionally, individuals with certain medical conditions or allergies may be required to complete a consent form to assess the suitability and safety of the vaccine for them.
4. It is always recommended to consult with a healthcare professional to determine if you need to fill out an influenza vaccine consent form.

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What is influenza vaccine consent form?

The influenza vaccine consent form is a document that individuals must sign to give their permission to receive the influenza vaccine.

Who is required to file influenza vaccine consent form?

Individuals who wish to receive the influenza vaccine are required to file the influenza vaccine consent form.

How to fill out influenza vaccine consent form?

To fill out the influenza vaccine consent form, individuals must provide their personal information, read and sign the consent section, and indicate any allergies or health conditions.

What is the purpose of influenza vaccine consent form?

The purpose of the influenza vaccine consent form is to ensure that individuals understand the risks and benefits of receiving the vaccine and give their informed consent.

What information must be reported on influenza vaccine consent form?

The influenza vaccine consent form must include personal information, consent to receive the vaccine, and any allergies or health conditions that may impact the vaccination.