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Influenza Consent Form Pediatric (20202021) www.wsmcmed.org Patient Name: ___ DOB: ___ Please complete the checklist below so the above patient can safely receive an appropriate influenza vaccine
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How to fill out pediatric flu vaccine consent

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How to fill out pediatric flu vaccine consent

01
Obtain the pediatric flu vaccine consent form from the healthcare provider or clinic.
02
Read through the form carefully and fill out all the required fields, including child's name, date of birth, and contact information.
03
Provide information about the child's medical history, including any allergies or previous reactions to vaccines.
04
Sign and date the form to indicate consent for the child to receive the flu vaccine.
05
Return the completed form to the healthcare provider or clinic before the child's scheduled vaccination appointment.

Who needs pediatric flu vaccine consent?

01
Children who are under the age of 18 and are getting a flu vaccine.
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Pediatric flu vaccine consent is a formal agreement from a parent or guardian permitting the administration of the flu vaccine to a child.
Parents or guardians of minors are required to file pediatric flu vaccine consent before a child can receive the flu vaccine.
To fill out pediatric flu vaccine consent, a parent or guardian needs to provide the child’s details, select the vaccine type, sign the document, and date it.
The purpose of pediatric flu vaccine consent is to ensure that a parent or guardian is informed about the vaccine and authorizes its administration to the child.
The information that must be reported includes the child's name, date of birth, the name of the vaccine, the date of administration, and the signature of the parent or guardian.
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