Please complete, submit and print this form, sign it and bring it with you.



Consent for Influenza Vaccine

Complete information about person to receive the vaccine.

Are you an LVHN/LVPG employee or volunteer? Yes No
If yes, please ask for employee health consent form.
Name: A value is required.
Date of Birth (ex. 09/09/1990): A value is required.Invalid format.
Age: A value is required.Invalid format.
Gender:
Male Female
Address: A value is required.
City: A value is required.
State: A value is required.
Zip Code: A value is required.
Phone (ex. (610) 555-1234): A value is required.Invalid format.
Doctor's Name: A value is required.
How did you hear about our clinic?: TV LVHN Website Physicians Office Radio Newspaper
Other   

Screening:

 
Have you received the flu vaccine before? Yes No
Do any of the following apply?  
  Severe reaction to the flu vaccine in the past Yes No
  Serious allergy to chicken eggs (If YES, please investigate options for vaccination with physician or allergist.) Yes No
  History of Guillain-Barre Syndrome (GBS) Yes No
  Currently sick with a fever Yes No

Participant/Parental Informed Consent Signature:
By signing I have received and agreed to the following:

  • Received and read the vaccine information sheet (dated 2013) regarding the Benefits and Risks of receiving the Influenza vaccine;
  • Had the opportunity to have questions answered regarding the vaccine;
  • Consented to be immunized or have my child immunized;
  • Understand that if my child is aged less than 9 years, I should consult my physician to determine if a second dose is indicated.

Please make a selection. I hereby release Lehigh Valley Health Network, its Hospitals, physicians, employees, agents, representatives, and assigns from any and all liability that may be associated with my (my child's) receipt of the flu vaccine.

Signature of person being immunized, or authorized representative:
Relationship:
If under age 18, need parental consent. Parent/Guardian signature:
Telephone Consent: Yes No Witnessed by:
Date: