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PEDIATRIC INFLUENZA IMMUNIZATION CONSENT (For under 18years or legal guardian) LE COM INSTITUTE FOR SUCCESSFUL AGING | 5535 Peach Street, Erie, PA 16509 (814) 868 3883 SCREENING QUESTIONNAIRE FOR

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How to fill out pediatric influenza immunization consent

01

Obtain a copy of the pediatric influenza immunization consent form.

02

Fill out all required fields with accurate information, including the child's name, date of birth, and current immunization history.

03

Review the consent form and make sure all information is complete and accurate.

04

Sign and date the consent form as the parent or legal guardian of the child.

05

Submit the completed consent form to the healthcare provider administering the influenza immunization.

Who needs pediatric influenza immunization consent?

01

Any parent or legal guardian of a child who wishes to have their child receive the pediatric influenza immunization needs to fill out the consent form.

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What is pediatric influenza immunization consent?

Pediatric influenza immunization consent is a form that allows parents or guardians to give permission for their child to receive the flu vaccine.

Who is required to file pediatric influenza immunization consent?

Parents or guardians of children under a certain age are required to file pediatric influenza immunization consent.

How to fill out pediatric influenza immunization consent?

Parents or guardians can fill out pediatric influenza immunization consent by providing their child's information, signing the form, and indicating their consent for the flu vaccine.

What is the purpose of pediatric influenza immunization consent?

The purpose of pediatric influenza immunization consent is to ensure that parents or guardians are aware of and consent to their child receiving the flu vaccine.

What information must be reported on pediatric influenza immunization consent?

Pediatric influenza immunization consent typically includes the child's name, date of birth, medical history, and the parent or guardian's contact information.

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