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Influenza Vaccine Order Form 2019 2020 Please fax order to the attention of the Health Unit Aide at the nearest Health Unit:Name of Physician, Clinic, Pharmacy or Group: Margaret Moss Health Unit
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How to fill out appendix 1 influenza vaccine
How to fill out appendix 1 influenza vaccine
01
To fill out appendix 1 for the influenza vaccine, follow these steps:
1. Start by writing your personal information such as your name, date of birth, and contact details in the designated fields.
02
Provide information about your medical history, including any allergies or medical conditions you may have.
03
Indicate the date of your previous influenza vaccination, if applicable.
04
Specify the type of influenza vaccine you are requesting, such as the standard quadrivalent vaccine or the high-dose vaccine for older adults.
05
Provide any additional information or requirements as specified by your healthcare provider or the vaccination program.
06
Sign and date the form to confirm that the information provided is accurate and complete.
Who needs appendix 1 influenza vaccine?
01
Appendix 1 for the influenza vaccine is typically required for individuals who fall into certain high-risk groups or who are eligible for specific flu vaccination programs.
02
These may include:
1. Pregnant women
03
Children aged 6 months to 5 years
04
Adults aged 65 years and older
05
Individuals with chronic medical conditions (e.g., asthma, diabetes, heart disease)
06
Healthcare workers and caregivers
07
Individuals living in long-term care facilities or nursing homes
08
It's important to consult with your healthcare provider or local health department to determine if you need to fill out appendix 1 for the influenza vaccine.
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