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INACTIVATED INFLUENZA VACCINATE:___SITE:___CONTACT:INFLUENZA PROGRAM PATIENT SCREENING CHECKLIST / CONSENT FORM / VACCINE ADMINISTRATION RECORDPLEASE PRINT CLEARLY Patient Name: ___ ___ ___ (Last)Birthdate:___

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How to fill out influenza program informed consent

01

Obtain the informed consent form from the healthcare provider administering the influenza program.

02

Read the form carefully to understand the information being provided and the risks involved.

03

Provide all necessary personal information as requested on the form.

04

Sign and date the form to indicate your agreement to participate in the influenza program.

05

Return the completed form to the healthcare provider before receiving the influenza vaccine.

Who needs influenza program informed consent?

01

Anyone who wishes to participate in an influenza program and receive the influenza vaccine needs to fill out the informed consent form.

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What is influenza program informed consent?

Influenza program informed consent is a form or document that provides information about the influenza program, its benefits, risks, and allows individuals to give their permission to participate.

Who is required to file influenza program informed consent?

Anyone who wishes to participate in the influenza program or receive vaccination must fill out the informed consent form.

How to fill out influenza program informed consent?

To fill out the influenza program informed consent, individuals must read the information provided, understand the risks and benefits, and sign the consent form.

What is the purpose of influenza program informed consent?

The purpose of influenza program informed consent is to ensure that individuals are fully informed about the program, its risks, benefits, and give their voluntary permission to participate.

What information must be reported on influenza program informed consent?

Influenza program informed consent must include information about the program, vaccine ingredients, possible side effects, and individual's rights.

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