Influenza Vaccine Consent Form – Employee – No

Employee Influenza Vaccine Consent - No Insurance

Nazareth Home Campus*
- Clifton
- Highlands
Employee Name*
First Last
Employee Date of Birth*
MM slash DD slash YYYY

(mm/dd/yyyy)
Do you wish to receive the influenza vaccine according to the recommended schedule? (This vaccine is offered annually.)*
- Yes
- No
Reasons for declining.
Already Received
- Select
Date Received
MM slash DD slash YYYY
Alergic
- Select
Comment
Other
- Select
Comment
I have read the CDC informational handout, have been given the opportunity to ask questions, and understand the flu information provided. This facility and its employees will not be held responsible for any adverse reactions to this vaccine now or in the following years. Local site reactions are expected in 5-10% of vaccine recipients. Less than 1% of vaccines have reported slight elevations of body temperature but severe allergic reactions have not been documented.
CDC Flu Shot Information Sheet
Signature*
Date*
MM slash DD slash YYYY