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Influenza Consent Form Adult (20202021) www.wsmcmed.org Patient Name: DOB: You are receiving:Influenza Vaccine Pneumococcal Vaccine Please complete the checklist below, so you can safely receive an

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How to fill out influenza consent

01

Step 1: Obtain the influenza consent form from the relevant authority or healthcare provider.

02

Step 2: Read the instructions and requirements stated on the consent form carefully.

03

Step 3: Provide your personal information accurately, including your full name, date of birth, and contact details.

04

Step 4: Review the information provided about the influenza vaccine, its benefits, and potential risks.

05

Step 5: If you agree to receive the influenza vaccine, sign and date the consent form.

06

Step 6: Return the completed consent form to the designated authority or healthcare provider.

07

Step 7: Follow any additional instructions provided by the authority or healthcare provider regarding the influenza vaccination process.

Who needs influenza consent?

01

Influenza consent is typically required for individuals who wish to receive the influenza vaccine. This includes individuals of all ages, including both children and adults. Some individuals with specific health conditions or sensitivities may need to consult their healthcare provider before receiving the vaccine.

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What is influenza consent?

Influenza consent refers to the permission given by an individual or their guardian to receive influenza vaccination.

Who is required to file influenza consent?

Individuals receiving the vaccination, or their legal guardians in case of minors, are required to file influenza consent.

How to fill out influenza consent?

Influenza consent can be filled out by providing personal information, details of the vaccine to be administered, and signing the form to confirm understanding and agreement.

What is the purpose of influenza consent?

The purpose of influenza consent is to ensure that individuals are informed about the vaccine and agree to its administration, thereby protecting their rights and health.

What information must be reported on influenza consent?

Influenza consent must report the recipient's name, date of birth, contact information, and consent for vaccination, along with any medical history relevant to the vaccine.

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