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Flu Vaccination
 

Vaccination Consent Form - Non-Employee

  
 

2012-13 Influenza Vaccination Program

 
 
TRIVALENT INACTIVATED INFLUENZA VACCINE (INJECTIBLE)
 
     
  Beaumont Hospitals Occupational Health Services  
     
  Influenza vaccine is recommended for ALL HEALTHCARE WORKERS.  
     
  It is also recommended for women who will be pregnant during the influenza season.  
     
  Please complete this form if you are planning to get a vaccination.  
     
 
       
  First Name:   Last Name  
  Male   Date of Birth:  
  Work Location    
  Volunteer 
   Physicians, Please enter your DR Number. (ex:DR1234)
   
 
     
  Contradictions for the influenza vaccine:  
  Review the following statements and select the appropriate answer for each.  
     
 
Yes   No  
  Allergy to eggs or egg products
  Have you ever had Guillain-Barre Syndrome?
  Do you have an allergy/hypersensitivity to Thimerosal?
  Do you have an allergy/hypersensitivity to Latex?
  Are you younger than 18 years old?
  Have you ever had a severe reaction to a flu shot?
     
   
       
       
      I understand that I will be given the influenza information sheet (VIS) and will be able to discuss the risks of influenza vaccination including the risks of not being vaccinated when I receive the vaccine.