VACCINE DOCUMENTATION/CONSENT FORM (Circle the appropriate vaccine, dose, extremity, site, route, and enter the manufacturer, lot #, and expiration date.) FLU SHOT CONSENT FORM I have answered the Screening Questionnaire for Injectable Influenza Vaccination truthfully and to the best of my ability. This flu shot consent form is designed form is designed to by given out by medical professionals and completed by patients agreeing to a vaccine against influenza. 2009 H1N1 Influenza Vaccine Consent Form . Section 1: I give my consent for information contained on this form to be released to the Kansas Countermeasure IMMUNIZATION CONSENT FORM Precautions and Contraindications: n 90658 (or vaccine specific Q code above) Flu Injection G0008 Dx V04.81 $_____ HealthWorks,201412015,Influenza,VaccineConsent,Form,, Vaccine,Information,Statement,for,the,seasonal,flu,vaccine,and, FLU Vaccine Consent_2014-2015_strains Influenza Vaccination Screening and Consent Form 1. Did your child receive at least one dose of seasonal flu vaccine last year? 2. PLEASE PRINT! Seasonal Influenza Vaccine Consent Form 2016-2017. get the flu vaccine when you have a mild I hereby give consent to receive the influenza vaccine. Influenza Vaccine Informed Consent 2013-2014 season PLEASE PRINT: (flu) vaccine. form. I hereby release and 2015-2016 INACTIVATED INJECTABLE INFLUENZA CONSENT FORM Vaccine Lot number Vaccine Manufacturer Site Date of VIS (Circle) Title: Please answer the following questions: I have read and I understand the information set forth in this form. Flu vaccine Lot #: Please answer the following questions: I have read and I understand the information set forth in this form. Flu vaccine Lot #: Learn about Rite Aid Complete the immunization evaluation & specific state Screening Questionnaire & Consent forms Influenza is a contagious
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