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Immunization Consent

Healthy Heart Cardiac : Immunization Consent

Influenza/Pneumococcal Immunization Consent Form

The Immunization Form is a crucial record that captures administered vaccines, ensuring up-to-date health records. Accurate vaccination information is essential for monitoring and maintaining individual and community health. Please provide complete and precise details for an effective immunization record.



Please complete the questions below for yourself or the person receiving the vaccine.

Are you currently sick with a fever?

Have you ever had a life threatening allergy to any component (or part) of the flu or pneumonia vaccine?
If yes, please describe:

Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving flu vaccine?

Have you ever had a pneumonia shot?

Are you a smoker or have a chronic medical condition such as asthma, heart or lung disease?
If yes, please describe:

Have you ever had a severe life threatening allergy to eggs or egg products?

Are you currently pregnant?

Do you have a history of asthma or wheezing?

Are you a child or adolescent receiving long-term aspirin therapy?

Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care?

Have you received any other vaccinations within the last 4 weeks?

Have you taken an antiviral medication for the flu within the last 48 hours?
Influenza Consent

I have read, or had explained to me, the Vaccine Information Statement about influenza vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. Irequest that the influenza vaccination be given to me (or the person named above for whom I am authorized to make this request). I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights.

Pneumococcal Consent

I have read, or had explained to me, the Vaccine Information Statement about pneumococcal vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. I request that the pneumococcal vaccination be given to me (or the person named above for whom I am authorized to make this request). I authorize the release of any medical or otherinformation necessary to process a Medicare or other insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights.

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