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Name: Fillable Online Questionnaire and Consent to Receive the Influvac Vaccine Fax Email Print - pdfFiller
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This document is a questionnaire and consent form for individuals receiving the vaccine. It includes personal information collection notices, screening questions regarding allergies and health conditions, and consent for vaccination. It must be completed before immunization at the clinic.

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How to fill out vaccine questionnaire and consent

01

Start by gathering personal information such as name, date of birth, and contact details.

02

Review the vaccine information provided, including the type of vaccine and any potential side effects.

03

Answer questions regarding your medical history, including allergies, previous vaccinations, and any chronic conditions.

04

Confirm informed consent by reading through the consent statement carefully.

05

Sign and date the questionnaire to acknowledge understanding and agreement to receive the vaccine.

06

Submit the completed questionnaire to the designated healthcare provider or organization.

Who needs vaccine questionnaire and consent?

01

Individuals receiving a vaccine, including children and adults.

02

Parents or guardians completing the form on behalf of minors.

03

Healthcare workers and staff administering vaccines.

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What is vaccine questionnaire and consent?

A vaccine questionnaire and consent is a document that collects information from individuals about their health history, allergies, and other relevant details, and provides consent for vaccination.

Who is required to file vaccine questionnaire and consent?

Individuals receiving the vaccine, or their legal guardians, are required to file a vaccine questionnaire and consent prior to vaccination.

How to fill out vaccine questionnaire and consent?

To fill out the vaccine questionnaire and consent, individuals should provide accurate personal information, complete health history questions, and sign the consent section to indicate their agreement.

What is the purpose of vaccine questionnaire and consent?

The purpose of the vaccine questionnaire and consent is to ensure that the vaccination is safe for the recipient based on their medical history and to obtain their informed consent.

What information must be reported on vaccine questionnaire and consent?

Information such as personal identification details, medical history, current medications, allergies, and consent to vaccination must be reported on the vaccine questionnaire and consent.

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