Printable Vaccine Consent Form

Except For The Last Two (2) Questions, A “Yes” Response To Any Other Question.

(b) the legal guardian of the patient; Have you taken an antiviral medication for the flu within the last 48 hours? Except for the last two (2) questions, a “yes” response to any other question. I consent to, or give consent for, the administration of the vaccine(s) marked above.

Do You Have Any Health Conditions.

Vaccine administration record (var)—informed consent for vaccination section c i certify that i am: I authorize the information to be forwarded to. Section a (please print clearly.) section b (the following questions will help us determine your eligibility for vaccination today.) do you feel sick today? Questions about the vaccine, and my questions have been answered to my satisfaction.

I Have Read, Or Had Explained To Me, The Vaccine Information Statement About Influenza Vaccination.

Tell your vaccination provider about all your medical conditions, including if you answer “yes” to any question. Further, i hereby give my consent to walgreens or duane reade and the licensed healthcare professional administering the vaccine, as applicable (each an “applicable provider”), to. By my signature below, i consent to the administration of the vaccine(s) by a pharmacist or a supervised student pharmacist or technician, or other authorized person, where permitted by. (a) the patient and at least 18 years of age;

Section B The Following Questions Will Help Us.

I understand the benefits and risks of the vaccination, the alternative modes or treatment, and i. Walgreens will send vaccination information from this visit to your doctor/primary care provider using the contact information provided below. Citation 14 others note that. I understand the benefits and risks of the vaccine(s).